Healthcare Provider Details

I. General information

NPI: 1609284876
Provider Name (Legal Business Name): KENIKA MILLER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2014
Last Update Date: 07/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6313 SANDY RIDGE ST UNIT 201
N LAS VEGAS NV
89081-3801
US

IV. Provider business mailing address

6313 SANDY RIDGE ST UNIT 201
N LAS VEGAS NV
89081-3801
US

V. Phone/Fax

Practice location:
  • Phone: 559-270-2193
  • Fax:
Mailing address:
  • Phone: 559-270-2193
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: