Provider Demographics
NPI:1093320590
Name:MILLER, KRISTINE RENEE
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:RENEE
Last Name:MILLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 GREENWOOD CT
Mailing Address - Street 2:
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035-8376
Mailing Address - Country:US
Mailing Address - Phone:440-453-9676
Mailing Address - Fax:
Practice Address - Street 1:307 GREENWOOD CT
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-8376
Practice Address - Country:US
Practice Address - Phone:440-453-9676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-10
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4705908376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4705908Medicaid