Provider Demographics
NPI:1174509087
Name:KIEKHAEFER, NINA MILLER (MD)
Entity Type:Individual
Prefix:DR
First Name:NINA
Middle Name:MILLER
Last Name:KIEKHAEFER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:NINA
Other - Middle Name:GWEN
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 104240
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65110-4240
Mailing Address - Country:US
Mailing Address - Phone:573-635-5264
Mailing Address - Fax:573-634-7423
Practice Address - Street 1:1241 W STADIUM BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-6023
Practice Address - Country:US
Practice Address - Phone:573-635-5264
Practice Address - Fax:573-634-7423
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO117863207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO204707103Medicaid
MO080176048OtherRAILROAD MEDICARE
MOCC7852OtherRR GROUP
MO000095262Medicare PIN
MO204707103Medicaid