Provider Demographics
NPI:1174077028
Name:VERMILLION, ILIANA I (NP-C)
Entity type:Individual
Prefix:
First Name:ILIANA
Middle Name:I
Last Name:VERMILLION
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3215 CAMPUS LOOP RD NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-3227
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3215 CAMPUS LOOP RD NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-3227
Practice Address - Country:US
Practice Address - Phone:470-578-7937
Practice Address - Fax:470-578-9004
Is Sole Proprietor?:No
Enumeration Date:2016-08-09
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN216175363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily