Provider Demographics
NPI:1427749589
Name:MILLER, KELSEY JANE
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:JANE
Last Name:MILLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 GILEAD RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:ONTARIO
Mailing Address - Zip Code:K0K1G0
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1991 SPROUL RD STE 28
Practice Address - Street 2:
Practice Address - City:BROOMALL
Practice Address - State:PA
Practice Address - Zip Code:19008-3514
Practice Address - Country:US
Practice Address - Phone:770-822-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-18
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG004018152W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program