Healthcare Provider Details

I. General information

NPI: 1306532791
Provider Name (Legal Business Name): KENDRA BROOKE DECKER MILLER FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KENDRA BROOKE DECKER

II. Dates (important events)

Enumeration Date: 04/18/2023
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

326 MAIN ST
CANON CITY CO
81212-3732
US

IV. Provider business mailing address

326 MAIN ST
CANON CITY CO
81212-3732
US

V. Phone/Fax

Practice location:
  • Phone: 719-441-9255
  • Fax:
Mailing address:
  • Phone: 719-441-9255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0998633-NP
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0200873
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: