Provider Demographics
NPI:1285113217
Name:MILLER, MALISSA (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:MALISSA
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:MALISSA
Other - Middle Name:A
Other - Last Name:WEBER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN, FNP-C
Mailing Address - Street 1:107 N MAIN ST STE 2A
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:IL
Mailing Address - Zip Code:62236-1757
Mailing Address - Country:US
Mailing Address - Phone:618-693-9313
Mailing Address - Fax:
Practice Address - Street 1:107 N MAIN ST STE 2A
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:IL
Practice Address - Zip Code:62236-1757
Practice Address - Country:US
Practice Address - Phone:618-693-9313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-10
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL277002437363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily