Healthcare Provider Details

I. General information

NPI: 1619609674
Provider Name (Legal Business Name): KAYLEE MILLER PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2022
Last Update Date: 09/23/2024
Certification Date: 09/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 N 7TH AVE STE 280
POCATELLO ID
83201-5788
US

IV. Provider business mailing address

1001 N 7TH AVE STE 205
POCATELLO ID
83201-5761
US

V. Phone/Fax

Practice location:
  • Phone: 208-239-1490
  • Fax:
Mailing address:
  • Phone: 208-239-1490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-7404
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberPT-7404
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT-7404
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: