Healthcare Provider Details

I. General information

NPI: 1497681803
Provider Name (Legal Business Name): TY MILLER NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2026
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 CROSSROADS PL
MOUNT VERNON IL
62864-6545
US

IV. Provider business mailing address

PO BOX 632331
CINCINNATI OH
45263-2331
US

V. Phone/Fax

Practice location:
  • Phone: 618-244-8100
  • Fax: 618-241-9079
Mailing address:
  • Phone: 812-450-6815
  • Fax: 812-450-6822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209036587
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: