Provider Demographics
NPI:1245492495
Name:MILLER, KAMALA MADELLE (LMT)
Entity type:Individual
Prefix:
First Name:KAMALA
Middle Name:MADELLE
Last Name:MILLER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 FOREST PARK CIR
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-4915
Mailing Address - Country:US
Mailing Address - Phone:850-769-9994
Mailing Address - Fax:850-769-9995
Practice Address - Street 1:216 FOREST PARK CIR
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4915
Practice Address - Country:US
Practice Address - Phone:850-769-9994
Practice Address - Fax:850-769-9995
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA38642174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC2226OtherBLUE CROSS BLUE SHIELD