Healthcare Provider Details

I. General information

NPI: 1457700734
Provider Name (Legal Business Name): SHELLEY A MILLER DNP, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2016
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5480 GOODMAN RD STE 1
OLIVE BRANCH MS
38654-7902
US

IV. Provider business mailing address

P O BOX 1000 DEPT 38
MEMPHIS TN
38148-0001
US

V. Phone/Fax

Practice location:
  • Phone: 662-893-9800
  • Fax: 662-893-9827
Mailing address:
  • Phone: 662-893-9800
  • Fax: 662-893-9827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number138762
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number21554
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number901643
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: