Provider Demographics
NPI:1700308574
Name:MILLER, KELLY WAYNE (LAT, ATC)
Entity Type:Individual
Prefix:MR
First Name:KELLY
Middle Name:WAYNE
Last Name:MILLER
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 LOCHSHIRE LN
Mailing Address - Street 2:
Mailing Address - City:WOODLEAF
Mailing Address - State:NC
Mailing Address - Zip Code:27054-9488
Mailing Address - Country:US
Mailing Address - Phone:704-526-5058
Mailing Address - Fax:
Practice Address - Street 1:1920 MCGUINN DR
Practice Address - Street 2:
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27265
Practice Address - Country:US
Practice Address - Phone:336-819-2800
Practice Address - Fax:336-887-5585
Is Sole Proprietor?:No
Enumeration Date:2017-07-12
Last Update Date:2018-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC31452255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer