Healthcare Provider Details

I. General information

NPI: 1548689946
Provider Name (Legal Business Name): EBONI CHAUNTAE MILLER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2014
Last Update Date: 03/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 TOWER RD NE STE 200
MARIETTA GA
30060-9412
US

IV. Provider business mailing address

400 TOWER RD NE STE 200
MARIETTA GA
30060-9412
US

V. Phone/Fax

Practice location:
  • Phone: 770-514-7550
  • Fax:
Mailing address:
  • Phone: 770-514-7550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number007152
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: