Provider Demographics
NPI:1437417011
Name:MILLER, LEE ANN (DNP-ACNP-BC)
Entity type:Individual
Prefix:
First Name:LEE
Middle Name:ANN
Last Name:MILLER
Suffix:
Gender:F
Credentials:DNP-ACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1875 ROAD 203
Mailing Address - Street 2:
Mailing Address - City:CLOVERDALE
Mailing Address - State:OH
Mailing Address - Zip Code:45827
Mailing Address - Country:US
Mailing Address - Phone:260-426-5431
Mailing Address - Fax:260-421-1834
Practice Address - Street 1:2121 LAKE AVENUE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5100
Practice Address - Country:US
Practice Address - Phone:260-426-5431
Practice Address - Fax:260-421-1834
Is Sole Proprietor?:No
Enumeration Date:2012-05-02
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71007636363LA2100X
OHCOA.13299363LA2100X
OH281647363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0065841Medicaid
OH0065841Medicaid