Provider Demographics
NPI:1073548350
Name:MILLER, KIMBERLY W (FNP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:W
Last Name:MILLER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 NORTH STATE STREET
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-5678
Mailing Address - Fax:601-984-5638
Practice Address - Street 1:2500 NORTH STATE STREET
Practice Address - Street 2:DEPARTMENT OF MEDICINE/DIVISION OF CARDIOLOGY
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-5630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR858593207RC0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP01236769OtherRAILROAD MEDICARE PTAN
MS0126138Medicaid
LA1191396Medicaid
MSRR 500030301OtherRAILROAD
MSP81465Medicare UPIN
MS0126138Medicaid
MSP01236769OtherRAILROAD MEDICARE PTAN
LA1191396Medicaid