Healthcare Provider Details

I. General information

NPI: 1750855599
Provider Name (Legal Business Name): TANYA D MILLER FAMILY NURSE PRACTIT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2019
Last Update Date: 03/06/2020
Certification Date: 03/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1724A OLD REYNOLDS ST
WAYCROSS GA
31501-1036
US

IV. Provider business mailing address

220 SIERRA ST
WAYCROSS GA
31503-9232
US

V. Phone/Fax

Practice location:
  • Phone: 912-283-1359
  • Fax: 912-283-1360
Mailing address:
  • Phone: 912-550-9277
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN183525
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberRN183525
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: