Provider Demographics
NPI:1306690425
Name:MILLER, KRISTIE (RD, LDN, CPT)
Entity type:Individual
Prefix:
First Name:KRISTIE
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:RD, LDN, CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:988 ROCKWELL LN
Mailing Address - Street 2:
Mailing Address - City:DYER
Mailing Address - State:IN
Mailing Address - Zip Code:46311-8002
Mailing Address - Country:US
Mailing Address - Phone:219-801-9677
Mailing Address - Fax:
Practice Address - Street 1:1326 NEW SENECA TPKE STE 16
Practice Address - Street 2:
Practice Address - City:SKANEATELES
Practice Address - State:NY
Practice Address - Zip Code:13152-8888
Practice Address - Country:US
Practice Address - Phone:315-710-0080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-15
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37003797A133V00000X
IL164006649133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered