Basic Information
| Provider Information | |||||||||
| NPI: | 1235899238 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | KAYLEE | ||||||||
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| Credential: | CSFA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 404 | ||||||||
| Address2: | |||||||||
| City: | BROOKS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302050404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4048620746 | ||||||||
| FaxNumber: | 4705145561 | ||||||||
| Practice Location | |||||||||
| Address1: | 4517 W MCINTOSH RD | ||||||||
| Address2: | |||||||||
| City: | GRIFFIN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302236129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4048620746 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2021 | ||||||||
| LastUpdateDate: | 02/01/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 246ZC0007X | 01 | GA | NB0117582 | OTHER |