Provider Demographics
NPI:1194037739
Name:PIASTA, JACLYN MILLER (APRN)
Entity Type:Individual
Prefix:MRS
First Name:JACLYN
Middle Name:MILLER
Last Name:PIASTA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:ANN
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:4523 HUNTING HOUND LN
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-6337
Mailing Address - Country:US
Mailing Address - Phone:908-227-4773
Mailing Address - Fax:
Practice Address - Street 1:4523 HUNTING HOUND LN
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-6337
Practice Address - Country:US
Practice Address - Phone:908-227-4773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-12
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA316599163W00000X, 363LW0102X
TX782340363LW0102X
AR004972363LW0102X
TX119517363LW0102X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No163W00000XNursing Service ProvidersRegistered Nurse
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX313030401Medicaid
TX313030401Medicaid