=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285229583
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA LANE MILLER PNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/08/2021
-----------------------------------------------------
Last Update Date | 11/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 128 MEDICAL PARK RD STE 200
-----------------------------------------------------
City | MOORESVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28117-8579
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-696-2085
-----------------------------------------------------
Fax | 704-660-0194
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1845
-----------------------------------------------------
City | STATESVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28687-1845
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-873-4277
-----------------------------------------------------
Fax | 704-978-3549
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 5015952
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Nurse Practitioner
-----------------------------------------------------
License Number | 5015952
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------