Basic Information
| Provider Information | |||||||||
| NPI: | 1821623232 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MICELI | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | ANTHONY | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 221 TECHNOLOGY PKWY NW | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301651369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7622351000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5470 MARTHA BERRY HWY NE | ||||||||
| Address2: | |||||||||
| City: | ARMUCHEE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301052302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7622353830 | ||||||||
| FaxNumber: | 7062919391 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2020 | ||||||||
| LastUpdateDate: | 03/20/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | RN242971 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.