Provider Demographics
NPI:1134365109
Name:MILLER, VERONICA YVETTE (OWNER)
Entity type:Individual
Prefix:
First Name:VERONICA
Middle Name:YVETTE
Last Name:MILLER
Suffix:
Gender:F
Credentials:OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 MONTEREY CIR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-8242
Mailing Address - Country:US
Mailing Address - Phone:770-572-1348
Mailing Address - Fax:770-994-4991
Practice Address - Street 1:310 MONTEREY CIR
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-8242
Practice Address - Country:US
Practice Address - Phone:770-572-1348
Practice Address - Fax:770-994-4991
Is Sole Proprietor?:No
Enumeration Date:2008-12-22
Last Update Date:2008-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053139355171WV0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WV0202XOther Service ProvidersContractorVehicle Modifications
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA263640417Medicare PIN