Healthcare Provider Details

I. General information

NPI: 1215381108
Provider Name (Legal Business Name): TARA SHAJUAN MILES FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2016
Last Update Date: 05/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

545 W BUTLER RD
GREENVILLE SC
29607-4833
US

IV. Provider business mailing address

211 BOXWOOD LN
ANDERSON SC
29621-7300
US

V. Phone/Fax

Practice location:
  • Phone: 864-299-1990
  • Fax: 864-299-9123
Mailing address:
  • Phone: 864-221-9352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number19424
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: