Healthcare Provider Details

I. General information

NPI: 1396474847
Provider Name (Legal Business Name): KAITLYN MARIE MILLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2022
Last Update Date: 06/09/2022
Certification Date: 06/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3890 PURDY DR
LITHIA SPRINGS GA
30122-1023
US

IV. Provider business mailing address

3890 PURDY DR
LITHIA SPRINGS GA
30122-1023
US

V. Phone/Fax

Practice location:
  • Phone: 678-739-1212
  • Fax:
Mailing address:
  • Phone: 678-739-1212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: