Provider Demographics
NPI:1215307863
Name:MILLER, LADAWN
Entity type:Individual
Prefix:MRS
First Name:LADAWN
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4765 KITTY DR
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38128
Mailing Address - Country:US
Mailing Address - Phone:901-517-3007
Mailing Address - Fax:
Practice Address - Street 1:877 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-2807
Practice Address - Country:US
Practice Address - Phone:901-545-8090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-25
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2839363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant