Provider Demographics
NPI:1558572107
Name:FENTON-MILLER, KATHY (RN, ANP-C)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:
Last Name:FENTON-MILLER
Suffix:
Gender:F
Credentials:RN, ANP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:13320 N BOULEVARD ST
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MI
Mailing Address - Zip Code:49097-1514
Mailing Address - Country:US
Mailing Address - Phone:269-649-2012
Mailing Address - Fax:269-649-3318
Practice Address - Street 1:13320 N BOULEVARD ST
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MI
Practice Address - Zip Code:49097-1514
Practice Address - Country:US
Practice Address - Phone:269-649-2012
Practice Address - Fax:269-649-3318
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MIKF230686363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1558572107Medicaid
MI1558572107Medicaid