=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124804489
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHANIE MILLER FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/04/2023
-----------------------------------------------------
Last Update Date | 09/04/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 235 SINGLETON RIDGE RD
-----------------------------------------------------
City | CONWAY
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29526-9136
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-347-2121
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2206 HAYSTACK WAY
-----------------------------------------------------
City | MYRTLE BEACH
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29579-3279
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-999-5661
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 27815
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------