Basic Information
| Provider Information | |||||||||
| NPI: | 1235153453 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MILLER | ||||||||
| OtherFirstName: | KELLY | ||||||||
| OtherMiddleName: | J | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 408 5TH AVE | ||||||||
| Address2: | |||||||||
| City: | INDIOLANTIC | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329034280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217272707 | ||||||||
| FaxNumber: | 3217272977 | ||||||||
| Practice Location | |||||||||
| Address1: | 408 5TH AVE | ||||||||
| Address2: | |||||||||
| City: | INDIALANTIC | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329034280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217272707 | ||||||||
| FaxNumber: | 3214098371 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 08/29/2008 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT20542 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.