Healthcare Provider Details

I. General information

NPI: 1164427324
Provider Name (Legal Business Name): CARLENE S MCMILLIAN F.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2005
Last Update Date: 11/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 W. 2ND STREET
DIXON MO
65459-0940
US

IV. Provider business mailing address

P.O. DRAWER 9900
DIXON MO
65459-0940
US

V. Phone/Fax

Practice location:
  • Phone: 573-759-3030
  • Fax: 573-759-3131
Mailing address:
  • Phone: 573-759-3030
  • Fax: 573-759-3131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number113217
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: