Provider Demographics
NPI:1649900747
Name:MCMILLAN, LEOLA (HAIR LOSS SPECIALIST)
Entity type:Individual
Prefix:
First Name:LEOLA
Middle Name:
Last Name:MCMILLAN
Suffix:
Gender:F
Credentials:HAIR LOSS SPECIALIST
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 11762
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27116-1762
Mailing Address - Country:US
Mailing Address - Phone:336-918-8521
Mailing Address - Fax:
Practice Address - Street 1:470 KNOLLWOOD ST
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3426
Practice Address - Country:US
Practice Address - Phone:336-986-9063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-13
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No1744P3200XOther Service ProvidersSpecialistProsthetics Case Management