Provider Demographics
NPI:1447384086
Name:MILLER, KELLY (RD, LD)
Entity Type:Individual
Prefix:MR
First Name:KELLY
Middle Name:
Last Name:MILLER
Suffix:
Gender:M
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1370 N INTERSTATE DR
Mailing Address - Street 2:SUITE 154
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73072-3376
Mailing Address - Country:US
Mailing Address - Phone:405-224-8111
Mailing Address - Fax:405-222-9587
Practice Address - Street 1:2222 W IOWA AVE
Practice Address - Street 2:
Practice Address - City:CHICKASHA
Practice Address - State:OK
Practice Address - Zip Code:73018-2738
Practice Address - Country:US
Practice Address - Phone:405-224-8111
Practice Address - Fax:405-222-9587
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKLD692133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered