Basic Information
| Provider Information | |||||||||
| NPI: | 1407003098 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | JULIE | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LIVELY | ||||||||
| OtherFirstName: | JULIE | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 716 COMMERCIAL AVE SW | ||||||||
| Address2: | |||||||||
| City: | NEW PHILADELPHIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446639367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303437605 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 716 COMMERCIAL AVE SW | ||||||||
| Address2: | |||||||||
| City: | NEW PHILADELPHIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446639367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303437605 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2008 | ||||||||
| LastUpdateDate: | 06/05/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | COA 10439-NP | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 164W00000X | RN 311853 | OH | N | Nursing Service Providers | Licensed Practical Nurse |
ID Information
| ID | Type | State | Issuer | Description | 2917731 | 05 | OH | MEDICAID |