Provider Demographics
NPI:1649204140
Name:MCMILLIN, PAMELA (CRNA)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:MCMILLIN
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 1:1914 NOTCHWOOD CT
Mailing Address - Street 2:
Mailing Address - City:LAKE WYLIE
Mailing Address - State:SC
Mailing Address - Zip Code:29710-6067
Mailing Address - Country:US
Mailing Address - Phone:704-718-5139
Mailing Address - Fax:
Practice Address - Street 1:1914 NOTCHWOOD CT
Practice Address - Street 2:
Practice Address - City:LAKE WYLIE
Practice Address - State:SC
Practice Address - Zip Code:29710-6067
Practice Address - Country:US
Practice Address - Phone:704-718-5139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC41130367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8052066Medicaid
SCNAN522Medicaid
NC2607357Medicare ID - Type Unspecified
NCP00331253Medicare ID - Type UnspecifiedRR MEDICARE