Provider Demographics
NPI:1114003126
Name:MCMILLION, KRISTEN M (MPT)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:M
Last Name:MCMILLION
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 DAVIS STUART ROAD
Mailing Address - Street 2:
Mailing Address - City:RONCEVERTE
Mailing Address - State:WV
Mailing Address - Zip Code:24970
Mailing Address - Country:US
Mailing Address - Phone:304-647-3987
Mailing Address - Fax:304-647-3990
Practice Address - Street 1:111 DAVIS STUART ROAD
Practice Address - Street 2:
Practice Address - City:RONCEVERTE
Practice Address - State:WV
Practice Address - Zip Code:24970
Practice Address - Country:US
Practice Address - Phone:304-647-3987
Practice Address - Fax:304-647-3990
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV001977174400000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7302139000Medicaid
WV550755833OtherWV WORKERS COMP
WVP00311422Medicare ID - Type UnspecifiedRR MEDICARE