Healthcare Provider Details

I. General information

NPI: 1831808922
Provider Name (Legal Business Name): CARLY ANN MILLAN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2022
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 S SAN GORGONIO AVE STE 202
BANNING CA
92220-6015
US

IV. Provider business mailing address

12 S SAN GORGONIO AVE STE 202
BANNING CA
92220-6015
US

V. Phone/Fax

Practice location:
  • Phone: 818-237-7955
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95023242
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: