Provider Demographics
NPI:1124583760
Name:MILLER, KENNETH R JR (RN)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:R
Last Name:MILLER
Suffix:JR
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3430 DUNRAN RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21222-5946
Mailing Address - Country:US
Mailing Address - Phone:443-586-5150
Mailing Address - Fax:
Practice Address - Street 1:3430 DUNRAN RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21222-5946
Practice Address - Country:US
Practice Address - Phone:443-586-5150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-07
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR199643163WE0003X, 163WH0200X, 163WH0500X, 163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No163WE0003XNursing Service ProvidersRegistered NurseEmergencyGroup - Multi-Specialty
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WH0500XNursing Service ProvidersRegistered NurseHemodialysis