Provider Demographics
NPI:1548689946
Name:MILLER, EBONI CHAUNTAE (PA-C)
Entity type:Individual
Prefix:MS
First Name:EBONI
Middle Name:CHAUNTAE
Last Name:MILLER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 TOWER RD NE STE 200
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-9412
Mailing Address - Country:US
Mailing Address - Phone:770-514-7550
Mailing Address - Fax:
Practice Address - Street 1:400 TOWER RD NE STE 200
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-9412
Practice Address - Country:US
Practice Address - Phone:770-514-7550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-14
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA007152363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant