Provider Demographics
NPI:1558921296
Name:MILES, COURTNEY LEANE (PMHNP)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:LEANE
Last Name:MILES
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2109 PROVIDENCE PARK LN
Mailing Address - Street 2:
Mailing Address - City:HERCULANEUM
Mailing Address - State:MO
Mailing Address - Zip Code:63048-1721
Mailing Address - Country:US
Mailing Address - Phone:314-223-6690
Mailing Address - Fax:
Practice Address - Street 1:1400 US HIGHWAY 61 STE 150
Practice Address - Street 2:
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-4141
Practice Address - Country:US
Practice Address - Phone:636-543-2230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-14
Last Update Date:2022-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013016420163WP0808X
MO2021033085363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health