Healthcare Provider Details

I. General information

NPI: 1023569019
Provider Name (Legal Business Name): KELLY MILLER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2016
Last Update Date: 10/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11102 LINDBERGH BUSINESS CT
SAINT LOUIS MO
63123-7810
US

IV. Provider business mailing address

11102 LINDBERGH BUSINESS CT
SAINT LOUIS MO
63123-7810
US

V. Phone/Fax

Practice location:
  • Phone: 314-540-6582
  • Fax: 314-206-3477
Mailing address:
  • Phone: 314-540-6582
  • Fax: 314-206-3477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2012017521
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: