Healthcare Provider Details

I. General information

NPI: 1497496012
Provider Name (Legal Business Name): KELLY E MILLER DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2022
Last Update Date: 10/13/2025
Certification Date: 10/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4407 MACCORKLE AVE SE
CHARLESTON WV
25304-2541
US

IV. Provider business mailing address

PO BOX 1680
HUNTINGTON WV
25717-1680
US

V. Phone/Fax

Practice location:
  • Phone: 304-925-0392
  • Fax:
Mailing address:
  • Phone: 304-781-5151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4788
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: