Provider Demographics
NPI:1588029425
Name:MILLER, GENNY (CHAIII)
Entity Type:Individual
Prefix:
First Name:GENNY
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:CHAIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3449 REZANOF DR E
Mailing Address - Street 2:
Mailing Address - City:KODIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99615-6952
Mailing Address - Country:US
Mailing Address - Phone:907-486-9800
Mailing Address - Fax:
Practice Address - Street 1:3449 REZANOF DR E
Practice Address - Street 2:
Practice Address - City:KODIAK
Practice Address - State:AK
Practice Address - Zip Code:99615-6952
Practice Address - Country:US
Practice Address - Phone:907-486-9800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-18
Last Update Date:2015-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK12-1225-III172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker