Provider Demographics
NPI:1487271318
Name:MCMILLAN, WENDEL
Entity type:Individual
Prefix:
First Name:WENDEL
Middle Name:
Last Name:MCMILLAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2653 CRANBROOK DR
Mailing Address - Street 2:
Mailing Address - City:HEPHZIBAH
Mailing Address - State:GA
Mailing Address - Zip Code:30815-6500
Mailing Address - Country:US
Mailing Address - Phone:706-951-8206
Mailing Address - Fax:
Practice Address - Street 1:3121 PEACH ORCHARD RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30906-3521
Practice Address - Country:US
Practice Address - Phone:706-792-5010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-26
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN083040164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty