Provider Demographics
NPI:1376254078
Name:MILLER, KIM VANESSA
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:VANESSA
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 1:1600 SARNO RD # 119J
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-4938
Mailing Address - Country:US
Mailing Address - Phone:321-414-2248
Mailing Address - Fax:877-515-0334
Practice Address - Street 1:1600 SARNO RD # 119J
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-4938
Practice Address - Country:US
Practice Address - Phone:321-414-2248
Practice Address - Fax:877-515-0334
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-13
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator