Provider Demographics
NPI:1821117482
Name:MILAM, KATHERINE EDWARDS (LDO LICENSED DISPENS)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:EDWARDS
Last Name:MILAM
Suffix:
Gender:F
Credentials:LDO LICENSED DISPENS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145A OLD HWY 70 EAST
Mailing Address - Street 2:
Mailing Address - City:BLACK MOUNTAIN
Mailing Address - State:NC
Mailing Address - Zip Code:28711
Mailing Address - Country:US
Mailing Address - Phone:828-669-5775
Mailing Address - Fax:828-669-6024
Practice Address - Street 1:145A OLD HWY 70 EAST
Practice Address - Street 2:
Practice Address - City:BLACK MOUNTAIN
Practice Address - State:NC
Practice Address - Zip Code:28711
Practice Address - Country:US
Practice Address - Phone:828-669-5775
Practice Address - Fax:828-669-6024
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC836156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8802025Medicaid
1184600001Medicare ID - Type Unspecified