Provider Demographics
NPI:1538794573
Name:MILLER, JACLYN KATE (CRNA)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:KATE
Last Name:MILLER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 BROOK DR
Mailing Address - Street 2:
Mailing Address - City:UNION HALL
Mailing Address - State:VA
Mailing Address - Zip Code:24176-2319
Mailing Address - Country:US
Mailing Address - Phone:330-979-0340
Mailing Address - Fax:
Practice Address - Street 1:1900 ELECTRIC RD
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-7494
Practice Address - Country:US
Practice Address - Phone:540-776-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-10
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024179350367500000X
VA0001250947163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse