Basic Information
| Provider Information | |||||||||
| NPI: | 1235569914 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCMILLAN | ||||||||
| FirstName: | TANIA | ||||||||
| MiddleName: | THERESA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 6 SHOEMAKER CT | ||||||||
| Address2: | |||||||||
| City: | CRAWFORDVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323270965 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8505594343 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1607 SAINT JAMES CT | ||||||||
| Address2: | |||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323085352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508780191 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2013 | ||||||||
| LastUpdateDate: | 11/18/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 150588 | GA | N | Nursing Service Providers | Registered Nurse | 163WG0600X | 9167103 | FL | Y | Nursing Service Providers | Registered Nurse | Gerontology |
No ID Information.