Provider Demographics
NPI:1235870825
Name:MILLER, RONNISHA (NIP)
Entity Type:Individual
Prefix:
First Name:RONNISHA
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:NIP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 NORTHSIDE DR
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1859
Mailing Address - Country:US
Mailing Address - Phone:229-469-0049
Mailing Address - Fax:
Practice Address - Street 1:235 NORTHSIDE DR
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1859
Practice Address - Country:US
Practice Address - Phone:229-469-0049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-06
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA863341051247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA86-3341051OtherNATIONAL MED SPA ASSOCIATION