Healthcare Provider Details

I. General information

NPI: 1396072120
Provider Name (Legal Business Name): HEATHER MILLER FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2009
Last Update Date: 02/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2116 MEGAN DRIVE SUITE 102
CAPE GIRARDEAU MO
63701
US

IV. Provider business mailing address

2116 MEGAN DRIVE 102
CAPE GIRARDEAU MO
63701-1727
US

V. Phone/Fax

Practice location:
  • Phone: 573-335-7546
  • Fax: 573-335-7550
Mailing address:
  • Phone: 573-335-7546
  • Fax: 573-335-7550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2009034583
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: