Provider Demographics
NPI:1619095171
Name:MIELKE, KELLY M (CAADE-CATC INTERN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:MIELKE
Suffix:
Gender:F
Credentials:CAADE-CATC INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 BUSINESS CENTER CIR
Mailing Address - Street 2:SUITE B
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91320-1184
Mailing Address - Country:US
Mailing Address - Phone:805-375-9100
Mailing Address - Fax:805-375-9920
Practice Address - Street 1:1125 BUSINESS CENTER CIR
Practice Address - Street 2:SUITE B
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91320-1184
Practice Address - Country:US
Practice Address - Phone:805-375-9100
Practice Address - Fax:805-375-9920
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program