Healthcare Provider Details

I. General information

NPI: 1891330734
Provider Name (Legal Business Name): KASEY MACMILLAN PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2019
Last Update Date: 01/17/2023
Certification Date: 01/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4697 HARRISON ST FL 3
BELLAIRE OH
43906-1338
US

IV. Provider business mailing address

4697 HARRISON ST FL 3
BELLAIRE OH
43906-1338
US

V. Phone/Fax

Practice location:
  • Phone: 740-968-7006
  • Fax:
Mailing address:
  • Phone: 740-968-7006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number443735
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0032357
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: