Provider Demographics
NPI:1841449832
Name:MILAM, KRISTAN ADEAN
Entity type:Individual
Prefix:
First Name:KRISTAN
Middle Name:ADEAN
Last Name:MILAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 E CHESTNUT ST
Mailing Address - Street 2:STE #310
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-5700
Mailing Address - Country:US
Mailing Address - Phone:502-589-6788
Mailing Address - Fax:
Practice Address - Street 1:401 E CHESTNUT ST
Practice Address - Street 2:STE #310
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-5700
Practice Address - Country:US
Practice Address - Phone:502-589-6788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-15
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KYTP806207R00000X
KY44324207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100132420Medicaid
KY7100132420Medicaid