Provider Demographics
NPI:1740427160
Name:MILLER, LISA ANN (FNP-BC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:MILLER
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:ANN
Other - Last Name:WHEATLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:601 S ENOTA DR NE
Mailing Address - Street 2:SUITE Q
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-2400
Mailing Address - Country:US
Mailing Address - Phone:770-219-7826
Mailing Address - Fax:770-321-9265
Practice Address - Street 1:597 S ENOTA DR NE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-2545
Practice Address - Country:US
Practice Address - Phone:770-533-6645
Practice Address - Fax:770-535-2642
Is Sole Proprietor?:No
Enumeration Date:2009-01-08
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN179064363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA511968OtherWELLCARE
GA01249758OtherAMERIGROUP
GA676775916AMedicaid
GA01249758OtherAMERIGROUP