=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760969554
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KAYLA NICOLE MILLER MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2018
-----------------------------------------------------
Last Update Date | 01/08/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 557 N WASHINGTON ST
-----------------------------------------------------
City | JANESVILLE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53548-2907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-754-6000
-----------------------------------------------------
Fax | 608-755-7892
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 557 N WASHINGTON ST
-----------------------------------------------------
City | JANESVILLE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53548-2907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-754-6000
-----------------------------------------------------
Fax | 608-755-7892
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QS0010X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | 98329
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number | 7186-851
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 73105-20
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------