=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679383616
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SEANEE KEANNA VIRTUE-MILLIGAN PN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2025
-----------------------------------------------------
Last Update Date | 01/19/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4813 RIDGE RD STE 113-644
-----------------------------------------------------
City | DOUGLASVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30134-6117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-923-4013
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4813 RIDGE RD STE 113-644
-----------------------------------------------------
City | DOUGLASVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30134-6117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-923-4013
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | LPN081275
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------