Basic Information
Provider Information | |||||||||
NPI: | 1033483060 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MILLICAN | ||||||||
FirstName: | ASHLEY | ||||||||
MiddleName: | B | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GIBSON | ||||||||
OtherFirstName: | ASHLEY | ||||||||
OtherMiddleName: | B | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1882 | ||||||||
Address2: |   | ||||||||
City: | ROME | ||||||||
State: | GA | ||||||||
PostalCode: | 301621882 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 28 JOHN DAVENPORT DR NW | ||||||||
Address2: |   | ||||||||
City: | ROME | ||||||||
State: | GA | ||||||||
PostalCode: | 301652536 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7062910584 | ||||||||
FaxNumber: | 7062900849 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/08/2012 | ||||||||
LastUpdateDate: | 05/21/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/21/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | RN186725 | GA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
No ID Information.