Provider Demographics
NPI:1639566862
Name:MILLER, RENAL R (CRNA)
Entity type:Individual
Prefix:MRS
First Name:RENAL
Middle Name:R
Last Name:MILLER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:RENAL
Other - Middle Name:R
Other - Last Name:NALLATAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:11401 GOSLING SHOALS WAY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40229-6515
Mailing Address - Country:US
Mailing Address - Phone:847-274-3367
Mailing Address - Fax:
Practice Address - Street 1:11401 GOSLING SHOALS WAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40229-6515
Practice Address - Country:US
Practice Address - Phone:847-274-3367
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-26
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.013201367500000X
KY3011573367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300006480Medicaid
KY7100499950Medicaid