Provider Demographics
NPI:1679897524
Name:MILLER, KELLY (LM, CPM)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:LM, CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:958A ARROYO ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76903-9345
Mailing Address - Country:US
Mailing Address - Phone:325-812-6525
Mailing Address - Fax:817-345-3533
Practice Address - Street 1:958A ARROYO ST
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76903-9345
Practice Address - Country:US
Practice Address - Phone:325-812-6525
Practice Address - Fax:817-345-3533
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-22
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX99095176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife