Provider Demographics
NPI:1164427324
Name:MCMILLIAN, CARLENE S (FNP)
Entity Type:Individual
Prefix:MRS
First Name:CARLENE
Middle Name:S
Last Name:MCMILLIAN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. DRAWER 9900
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:MO
Mailing Address - Zip Code:65459-0940
Mailing Address - Country:US
Mailing Address - Phone:573-759-3030
Mailing Address - Fax:573-759-3131
Practice Address - Street 1:206 W. 2ND STREET
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:MO
Practice Address - Zip Code:65459-0940
Practice Address - Country:US
Practice Address - Phone:573-759-3030
Practice Address - Fax:573-759-3131
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2009-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO113217363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP51939Medicare UPIN
MO000013585Medicare ID - Type Unspecified