MEDICARE: QUARSHAE LYSONDRA MILLER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172A00000X	Driver

General Provider Information

NPI Number	:	1952040214
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	QUARSHAE LYSONDRA MILLER

Provider Business Mailing Address
First Line	:	528 ELLINGSWORTH LN
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28214-8464
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	528 ELLINGSWORTH LN
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28214-8464
Country	:	US
Telephone Number	:	980-319-2907
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/03/2022
Last Update Date	:	06/03/2022

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