Provider Demographics
NPI:1265099238
Name:MILLER, KANISHA L (APRN)
Entity type:Individual
Prefix:
First Name:KANISHA
Middle Name:L
Last Name:MILLER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32305-7006
Mailing Address - Country:US
Mailing Address - Phone:850-443-3057
Mailing Address - Fax:
Practice Address - Street 1:201 W PLYMOUTH AVE
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-2753
Practice Address - Country:US
Practice Address - Phone:407-732-4272
Practice Address - Fax:407-732-4579
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-24
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
FLARNP11002017363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health