Provider Demographics
NPI:1801034707
Name:MILLER, KEITRA ANN
Entity Type:Individual
Prefix:
First Name:KEITRA
Middle Name:ANN
Last Name:MILLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:A CO. 121 CSH
Mailing Address - Street 2:762
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96205
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:A CO. 121 CSH
Practice Address - Street 2:762
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96205
Practice Address - Country:US
Practice Address - Phone:706-478-0112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-30
Last Update Date:2009-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX199358286500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes286500000XHospitalsMilitary Hospital