Provider Demographics
NPI:1114003126
Name:MCMILLION, KRISTEN M (MPT)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:M
Last Name:MCMILLION
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 DAVIS STUART ROAD
Mailing Address - Street 2:
Mailing Address - City:RONCEVERTE
Mailing Address - State:WV
Mailing Address - Zip Code:24970
Mailing Address - Country:US
Mailing Address - Phone:304-647-3987
Mailing Address - Fax:304-647-3990
Practice Address - Street 1:111 DAVIS STUART ROAD
Practice Address - Street 2:
Practice Address - City:RONCEVERTE
Practice Address - State:WV
Practice Address - Zip Code:24970
Practice Address - Country:US
Practice Address - Phone:304-647-3987
Practice Address - Fax:304-647-3990
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV001977174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7302139000Medicaid
WVMC4031421Medicare ID - Type UnspecifiedMEDICARE
WVP00311422Medicare ID - Type UnspecifiedRR MEDICARE