Provider Demographics
NPI:1942296009
Name:MILLER, LISA M (FNP-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:MILLER
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1116 MILLIS AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:BOONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47601-2226
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1116 MILLIS AVE
Practice Address - Street 2:STE 101
Practice Address - City:BOONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47601-2292
Practice Address - Country:US
Practice Address - Phone:812-897-7107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001974A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200303730Medicaid
KY78015146Medicaid
IN200303730Medicaid
IN232170BMedicare PIN
IN15D1043196OtherCLIA SECONDARY LOCATION
IN230770BMedicare PIN
IN000000385273OtherANTHEM BC/BS SECONDARY LO
INMM1294343OtherDEA PRIMARY LOCATION
IN000000383043OtherANTHEM BC/BS
IN15D1043329OtherCLIA PRIMARY LOCATION
IN200303730Medicaid