Provider Demographics
NPI:1881264232
Name:MCMILLAN, PENNY ANN
Entity type:Individual
Prefix:
First Name:PENNY
Middle Name:ANN
Last Name:MCMILLAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 W LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:NEW LEXINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43764-1018
Mailing Address - Country:US
Mailing Address - Phone:740-607-7911
Mailing Address - Fax:
Practice Address - Street 1:127 W LINCOLN ST
Practice Address - Street 2:
Practice Address - City:NEW LEXINGTON
Practice Address - State:OH
Practice Address - Zip Code:43764-1018
Practice Address - Country:US
Practice Address - Phone:740-607-7911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-28
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2977006374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2977006Medicaid