Provider Demographics
NPI:1235764952
Name:MILLER, KELLY LYNN
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
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 1:10275 W PLUM TREE CIR APT 102
Mailing Address - Street 2:
Mailing Address - City:HALES CORNERS
Mailing Address - State:WI
Mailing Address - Zip Code:53130-2658
Mailing Address - Country:US
Mailing Address - Phone:319-310-4230
Mailing Address - Fax:
Practice Address - Street 1:1130 W SUNSET DR
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53189-8422
Practice Address - Country:US
Practice Address - Phone:262-446-5169
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-04
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16421-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty