Provider Demographics
NPI:1790038438
Name:MILLER, KEVIN DAVID (LPN)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:DAVID
Last Name:MILLER
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4273 CORPORATE WAY
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-5321
Mailing Address - Country:US
Mailing Address - Phone:989-953-4357
Mailing Address - Fax:989-953-4358
Practice Address - Street 1:4273 CORPORATE WAY
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858
Practice Address - Country:US
Practice Address - Phone:989-953-4357
Practice Address - Fax:989-953-4358
Is Sole Proprietor?:No
Enumeration Date:2012-10-18
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703107357164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse