Provider Demographics
NPI:1316223027
Name:MILLRY PEDIATRIC CLINIC, LLC
Entity Type:Organization
Organization Name:MILLRY PEDIATRIC CLINIC, LLC
Other - Org Name:MILLRY FAMILY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PEDIATRIC NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:MCNEASE
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:251-846-3233
Mailing Address - Street 1:PO BOX 465
Mailing Address - Street 2:
Mailing Address - City:MILLRY
Mailing Address - State:AL
Mailing Address - Zip Code:36558-0465
Mailing Address - Country:US
Mailing Address - Phone:251-846-3233
Mailing Address - Fax:251-846-3224
Practice Address - Street 1:73 LONG STREET
Practice Address - Street 2:
Practice Address - City:MILLRY
Practice Address - State:AL
Practice Address - Zip Code:36558
Practice Address - Country:US
Practice Address - Phone:251-846-3233
Practice Address - Fax:251-846-3224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-26
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL137591Medicaid
AL136193Medicaid