Provider Demographics
NPI:1790793594
Name:MILLER, SHELLEY RENEA (RN MSN FNP-C)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:RENEA
Last Name:MILLER
Suffix:
Gender:F
Credentials:RN MSN FNP-C
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 2377
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:VA
Mailing Address - Zip Code:24266-2607
Mailing Address - Country:US
Mailing Address - Phone:276-889-3700
Mailing Address - Fax:276-889-5505
Practice Address - Street 1:495 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:VA
Practice Address - Zip Code:24266
Practice Address - Country:US
Practice Address - Phone:276-889-3700
Practice Address - Fax:276-889-5505
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024000081363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010204534Medicaid
VA010204518Medicaid
VA008795L11Medicare ID - Type Unspecified
VA010204518Medicaid