Basic Information
| Provider Information | |||||||||
| NPI: | 1104395904 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | KATHERINE | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PHELAN | ||||||||
| OtherFirstName: | KATHERINE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 550 GAGE BLVD STE 101 | ||||||||
| Address2: | |||||||||
| City: | RICHLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993529532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099423627 | ||||||||
| FaxNumber: | 5096272983 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 GOETHALS DR STE F | ||||||||
| Address2: | |||||||||
| City: | RICHLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993523301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099423272 | ||||||||
| FaxNumber: | 5099423273 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2018 | ||||||||
| LastUpdateDate: | 06/17/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP60924861 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | AP138937 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | N360945524 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.