Provider Demographics
NPI:1588661599
Name:MILLER, MISTY N (CRNA)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:N
Last Name:MILLER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6270
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71136-6270
Mailing Address - Country:US
Mailing Address - Phone:318-683-0411
Mailing Address - Fax:318-603-5461
Practice Address - Street 1:255 BERT KOUNS LOOP
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-8150
Practice Address - Country:US
Practice Address - Phone:318-683-0411
Practice Address - Fax:318-603-5461
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN086359367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1154911Medicaid
LA1154911Medicaid