Basic Information
| Provider Information | |||||||||
| NPI: | 1053625426 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | KENDAL | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2712 VALLEY CT | ||||||||
| Address2: | |||||||||
| City: | MANDEVILLE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704488475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9855074588 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1100 ANDRE ST STE 300 | ||||||||
| Address2: | YPS - CREDENTIALING | ||||||||
| City: | NEW IBERIA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705632159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3373649225 | ||||||||
| FaxNumber: | 3373646094 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2010 | ||||||||
| LastUpdateDate: | 09/10/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | AP06178 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 2125630 | 05 | LA | MEDICAID | 1053625426 | 01 | LA | BCBS OF LA | OTHER |