Provider Demographics
NPI:1609199363
Name:MILLER, KELLY ANNE (LPT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANNE
Last Name:MILLER
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 GRANT AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19114-1528
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3600 GRANT AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19114-1528
Practice Address - Country:US
Practice Address - Phone:215-677-0400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-10
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT020411225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2154416OtherPA BLUE SHIELD
PA3769514000OtherIBC
PA102532415-0001Medicaid
PA2154416OtherPA BLUE SHIELD