Provider Demographics
NPI:1063956233
Name:HARRISON, MILLICENT R (CRNP)
Entity type:Individual
Prefix:
First Name:MILLICENT
Middle Name:R
Last Name:HARRISON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1414 ELBA HWY
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:AL
Mailing Address - Zip Code:36079-6020
Mailing Address - Country:US
Mailing Address - Phone:334-670-6726
Mailing Address - Fax:334-670-6731
Practice Address - Street 1:105 E WATTS ST
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330-2511
Practice Address - Country:US
Practice Address - Phone:334-393-5437
Practice Address - Fax:334-393-4185
Is Sole Proprietor?:No
Enumeration Date:2016-12-07
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-140707363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1-140707OtherSTATE LICENSE
AL195503Medicaid