Basic Information
| Provider Information | |||||||||
| NPI: | 1821328121 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | ELESA | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1367 RUTHERFORD ST | ||||||||
| Address2: | |||||||||
| City: | UNION CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 382615873 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7312861900 | ||||||||
| FaxNumber: | 7312861939 | ||||||||
| Practice Location | |||||||||
| Address1: | 1004 GREYSTONE SQ | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383053580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316641773 | ||||||||
| FaxNumber: | 7316641751 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2010 | ||||||||
| LastUpdateDate: | 11/05/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | 14222 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 363L00000X | APN14222 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1518161 | 05 | TN | MEDICAID |