1063487288 NPI number — MRS. CREDONNA L MILLER AUD

Table of content: MRS. CREDONNA L MILLER AUD (NPI 1063487288)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063487288 NPI number — MRS. CREDONNA L MILLER AUD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MILLER
Provider First Name:
CREDONNA
Provider Middle Name:
L
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
AUD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063487288
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/03/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5 MEDICAL PARK DR
Provider Second Line Business Mailing Address:
STE 101
Provider Business Mailing Address City Name:
BENTON
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72015-3729
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-778-3868
Provider Business Mailing Address Fax Number:
501-317-1704

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5 MEDICAL PARK DR
Provider Second Line Business Practice Location Address:
STE 101
Provider Business Practice Location Address City Name:
BENTON
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72015-3729
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-778-3868
Provider Business Practice Location Address Fax Number:
501-317-1704
Provider Enumeration Date:
02/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 231H00000X , with the licence number:  A#90 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 131885720 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 621697738 . This is a "TAX ID #" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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