Provider Demographics
NPI:1336705078
Name:MILLER, LISSA ANNE
Entity type:Individual
Prefix:
First Name:LISSA
Middle Name:ANNE
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 1:615 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:KEWAUNEE
Mailing Address - State:WI
Mailing Address - Zip Code:54216-1529
Mailing Address - Country:US
Mailing Address - Phone:920-256-1470
Mailing Address - Fax:
Practice Address - Street 1:615 CENTER ST
Practice Address - Street 2:
Practice Address - City:KEWAUNEE
Practice Address - State:WI
Practice Address - Zip Code:54216-1529
Practice Address - Country:US
Practice Address - Phone:920-256-1470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-17
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY343800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343800000XTransportation ServicesSecured Medical Transport (VAN)