Healthcare Provider Details

I. General information

NPI: 1902135023
Provider Name (Legal Business Name): MRS. JESSICA L MILLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2009
Last Update Date: 09/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W4054 LINDEN DR
MALONE WI
53049-1694
US

IV. Provider business mailing address

2235 BROOKVIEW CT UNIT D
OSHKOSH WI
54904-7851
US

V. Phone/Fax

Practice location:
  • Phone: 920-921-1404
  • Fax:
Mailing address:
  • Phone: 920-606-6657
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number166830-030
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: