Provider Demographics
NPI:1417990979
Name:MILLER, JOLYNN (PA)
Entity Type:Individual
Prefix:
First Name:JOLYNN
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11141 PARKVIEW PLAZA DR STE 325
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1714
Practice Address - Country:US
Practice Address - Phone:260-425-5400
Practice Address - Fax:260-425-5417
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000714A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
INO90430VVVVMedicare ID - Type Unspecified
INP90704Medicare UPIN