Provider Demographics
NPI:1093221210
Name:MILLER, LISA (LPN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2048 FRIAR TUCK CIR
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-2754
Mailing Address - Country:US
Mailing Address - Phone:517-499-6946
Mailing Address - Fax:
Practice Address - Street 1:2048 FRIAR TUCK CIR
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-2754
Practice Address - Country:US
Practice Address - Phone:517-499-6946
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-26
Last Update Date:2017-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374J00000X
MI4703097969164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Multi-Specialty
No374J00000XNursing Service Related ProvidersDoulaGroup - Multi-Specialty