Healthcare Provider Details

I. General information

NPI: 1124583760
Provider Name (Legal Business Name): KENNETH R MILLER JR. RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2019
Last Update Date: 02/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3430 DUNRAN RD
BALTIMORE MD
21222-5946
US

IV. Provider business mailing address

3430 DUNRAN RD
BALTIMORE MD
21222-5946
US

V. Phone/Fax

Practice location:
  • Phone: 443-586-5150
  • Fax:
Mailing address:
  • Phone: 443-586-5150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License NumberR199643
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License NumberR199643
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code163WH0500X
TaxonomyHemodialysis Registered Nurse
License NumberR199643
License Number StateMD
# 4
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberR199643
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: