Provider Demographics
NPI:1104663095
Name:MILLER, KASSITY
Entity type:Individual
Prefix:
First Name:KASSITY
Middle Name:
Last Name:MILLER
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2587 CREEK RD
Mailing Address - Street 2:
Mailing Address - City:NEW WATERFORD
Mailing Address - State:OH
Mailing Address - Zip Code:44445-9713
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10845 TOWN CENTER BLVD STE 108
Practice Address - Street 2:
Practice Address - City:DUNKIRK
Practice Address - State:MD
Practice Address - Zip Code:20754-2712
Practice Address - Country:US
Practice Address - Phone:410-650-4346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-09
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
MDC0009620363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical