Provider Demographics
NPI:1336400514
Name:MILES, KELLEY OLIVIA (NP(NURSE PRACTITIONE)
Entity Type:Individual
Prefix:MS
First Name:KELLEY
Middle Name:OLIVIA
Last Name:MILES
Suffix:
Gender:F
Credentials:NP(NURSE PRACTITIONE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 23RD STREET
Mailing Address - Street 2:BUILDING 9, 2ND FLOOR
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94110
Mailing Address - Country:US
Mailing Address - Phone:415-206-3887
Mailing Address - Fax:415-206-3373
Practice Address - Street 1:2550 23RD STREET
Practice Address - Street 2:BUILDING 9, 2ND FLOOR
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110
Practice Address - Country:US
Practice Address - Phone:415-206-3887
Practice Address - Fax:415-206-3373
Is Sole Proprietor?:No
Enumeration Date:2012-06-04
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60290894363L00000X
CANP-22661363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2017920Medicaid
WA2017920Medicaid