Provider Demographics
NPI:1972280592
Name:MILLER, KAYLA
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:
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 1:341 SAINT JOHNS WAY
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-2436
Mailing Address - Country:US
Mailing Address - Phone:208-750-7464
Mailing Address - Fax:208-750-7467
Practice Address - Street 1:500 8TH AVE RM 205
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-2691
Practice Address - Country:US
Practice Address - Phone:208-792-2251
Practice Address - Fax:208-792-2882
Is Sole Proprietor?:No
Enumeration Date:2023-07-05
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID76807363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2255568Medicaid