Provider Demographics
NPI:1780181834
Name:MILLS, JERAKHINE N (FNP)
Entity Type:Individual
Prefix:
First Name:JERAKHINE
Middle Name:N
Last Name:MILLS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5160 D E PONCE DELEON AVE
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083
Mailing Address - Country:US
Mailing Address - Phone:954-305-4838
Mailing Address - Fax:
Practice Address - Street 1:1810 MULKEY RD STE 105
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1132
Practice Address - Country:US
Practice Address - Phone:678-540-7597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-06
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN235396163WG0000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN235396OtherRN LICENSE
GARN235396OtherFNP LICENSE