Provider Demographics
NPI:1083120695
Name:MILLER, JOANNA LYNN (PA)
Entity type:Individual
Prefix:
First Name:JOANNA
Middle Name:LYNN
Last Name:MILLER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JOANNA
Other - Middle Name:LYNN
Other - Last Name:DEVRIES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:258 W MEADOWLAND LN
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20164-1141
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:43300 SOUTHERN WALK PLAZA, SUITE 100
Practice Address - Street 2:
Practice Address - City:BROADLANDS
Practice Address - State:VA
Practice Address - Zip Code:20148-4463
Practice Address - Country:US
Practice Address - Phone:571-252-7353
Practice Address - Fax:571-223-5340
Is Sole Proprietor?:No
Enumeration Date:2017-12-19
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110008295363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1083120695Medicaid