Provider Demographics
NPI:1699115360
Name:MILLER, KATHLEEN ANN (RD, LDN, CDE)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ANN
Last Name:MILLER
Suffix:
Gender:F
Credentials:RD, LDN, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3825 HIGHLAND AVE
Mailing Address - Street 2:TOWER 2, SUITE 303
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-1552
Mailing Address - Country:US
Mailing Address - Phone:630-275-4872
Mailing Address - Fax:630-275-1290
Practice Address - Street 1:3825 HIGHLAND AVE
Practice Address - Street 2:TOWER 2, SUITE 303
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-1552
Practice Address - Country:US
Practice Address - Phone:630-275-4872
Practice Address - Fax:630-275-1290
Is Sole Proprietor?:No
Enumeration Date:2013-06-26
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164001544133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK00888Medicare PIN