Basic Information
| Provider Information | |||||||||
| NPI: | 1295490431 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCMILLON | ||||||||
| FirstName: | MYA | ||||||||
| MiddleName: | SHANICE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 806 W MCWILLIAMS AVE | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891063500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7029132557 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3920 W ANN RD | ||||||||
| Address2: | |||||||||
| City: | NORTH LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890313839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7024374673 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2021 | ||||||||
| LastUpdateDate: | 11/02/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Contractor |
No ID Information.