Healthcare Provider Details

I. General information

NPI: 1194092346
Provider Name (Legal Business Name): KRYSTLE C MILLIKAN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2011
Last Update Date: 09/16/2025
Certification Date: 09/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3405 DALLAS HWY SW STE 200
MARIETTA GA
30064-6426
US

IV. Provider business mailing address

3405 DALLAS HWY SW STE 200
MARIETTA GA
30064-6426
US

V. Phone/Fax

Practice location:
  • Phone: 678-802-8665
  • Fax: 678-540-4250
Mailing address:
  • Phone: 678-802-8665
  • Fax: 678-540-4250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number006319
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: