Healthcare Provider Details

I. General information

NPI: 1265674402
Provider Name (Legal Business Name): PAMELA G MILLER CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2009
Last Update Date: 06/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1805 VERNON RD SUITE C
LAGRANGE GA
30240-3871
US

IV. Provider business mailing address

138 CHANDLERS RUN
NEWNAN GA
30263-6196
US

V. Phone/Fax

Practice location:
  • Phone: 706-812-9902
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN161397 CRNA
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberTMP141143
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: