=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144710799
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY SUE MILLER MPH, MSN, APRN, NP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2018
-----------------------------------------------------
Last Update Date | 06/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10000 BAY PINES BLVD
-----------------------------------------------------
City | BAY PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33744-8200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-398-6661
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4846 MIRAMAR DR UNIT 1123
-----------------------------------------------------
City | MADEIRA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33708-3384
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-832-2494
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 4704218653
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------