Provider Demographics
NPI:1154450062
Name:MILLER, KELLI NICOLE (LAC)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:NICOLE
Last Name:MILLER
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1375 FARNHAM PT APT 301
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80904-5211
Mailing Address - Country:US
Mailing Address - Phone:719-569-2915
Mailing Address - Fax:
Practice Address - Street 1:3314 MESA RD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80904-1036
Practice Address - Country:US
Practice Address - Phone:719-428-2202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACU.0002466171100000X
WI293-055171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist