Provider Demographics
NPI: | 1841802741 |
---|---|
Name: | MILLER, SHASTI M (FNP-BC) |
Entity Type: | Individual |
Prefix: | |
First Name: | SHASTI |
Middle Name: | M |
Last Name: | MILLER |
Suffix: | |
Gender: | F |
Credentials: | FNP-BC |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 3443 DICKERSON PIKE STE 680 |
Mailing Address - Street 2: | |
Mailing Address - City: | NASHVILLE |
Mailing Address - State: | TN |
Mailing Address - Zip Code: | 37207-2537 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 615-865-3322 |
Mailing Address - Fax: | 615-467-6692 |
Practice Address - Street 1: | 3443 DICKERSON PIKE STE 680 |
Practice Address - Street 2: | |
Practice Address - City: | NASHVILLE |
Practice Address - State: | TN |
Practice Address - Zip Code: | 37207-2537 |
Practice Address - Country: | US |
Practice Address - Phone: | 615-865-3322 |
Practice Address - Fax: | 615-467-6692 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2020-08-20 |
Last Update Date: | 2022-02-23 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
TN | 27394 | 363L00000X, 363LF0000X, 363L00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
TN | Q064742 | Medicaid |