Provider Demographics
NPI:1235153453
Name:MILLER, KELLY J (MPT)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:J
Last Name:MILLER
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:MISS
Other - First Name:KELLY
Other - Middle Name:J
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:408 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:INDIOLANTIC
Mailing Address - State:FL
Mailing Address - Zip Code:32903-4280
Mailing Address - Country:US
Mailing Address - Phone:321-727-2707
Mailing Address - Fax:321-727-2977
Practice Address - Street 1:408 5TH AVE
Practice Address - Street 2:
Practice Address - City:INDIALANTIC
Practice Address - State:FL
Practice Address - Zip Code:32903-4280
Practice Address - Country:US
Practice Address - Phone:321-727-2707
Practice Address - Fax:321-409-8371
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT20542225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU4959AMedicare PIN