Provider Demographics
NPI:1821328121
Name:MILLER, ELESA ANN (FNP)
Entity Type:Individual
Prefix:
First Name:ELESA
Middle Name:ANN
Last Name:MILLER
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 1:1367 RUTHERFORD ST
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:TN
Mailing Address - Zip Code:38261-5873
Mailing Address - Country:US
Mailing Address - Phone:731-286-1900
Mailing Address - Fax:731-286-1939
Practice Address - Street 1:1004 GREYSTONE SQ
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-3580
Practice Address - Country:US
Practice Address - Phone:731-664-1773
Practice Address - Fax:731-664-1751
Is Sole Proprietor?:No
Enumeration Date:2010-01-08
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN14222363LP2300X
TNAPN14222363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1518161Medicaid