Healthcare Provider Details

I. General information

NPI: 1285229583
Provider Name (Legal Business Name): JESSICA LANE MILLER PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2021
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 MEDICAL PARK RD STE 200
MOORESVILLE NC
28117-8579
US

IV. Provider business mailing address

PO BOX 1845
STATESVILLE NC
28687-1845
US

V. Phone/Fax

Practice location:
  • Phone: 704-696-2085
  • Fax: 704-660-0194
Mailing address:
  • Phone: 704-873-4277
  • Fax: 704-978-3549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5015952
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number5015952
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: