Provider Demographics
NPI:1235691619
Name:MILLER, KELLY MARIE (FNP-C)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:MILLER
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2305 GEORGIA ST
Mailing Address - Street 2:
Mailing Address - City:LOUISIANA
Mailing Address - State:MO
Mailing Address - Zip Code:63353-2559
Mailing Address - Country:US
Mailing Address - Phone:573-754-4584
Mailing Address - Fax:
Practice Address - Street 1:1420 S BUSINESS 61 STE DEF
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:MO
Practice Address - Zip Code:63334-5230
Practice Address - Country:US
Practice Address - Phone:573-324-5562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-03
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019010659207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine