Healthcare Provider Details

I. General information

NPI: 1164968749
Provider Name (Legal Business Name): KELLI JO MILLER FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2017
Last Update Date: 06/05/2023
Certification Date: 06/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

173 S MAIN ST
RUTLAND VT
05701-4713
US

IV. Provider business mailing address

165 UNIVERSITY DR
AMHERST MA
01002-8900
US

V. Phone/Fax

Practice location:
  • Phone: 802-772-4165
  • Fax: 802-855-8489
Mailing address:
  • Phone: 682-331-9534
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number101.0134229
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP132850
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number221431
License Number StateME
# 4
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAP132850
License Number StateTX
# 5
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAPN.0995662
License Number StateCO
# 6
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2345722
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: