Provider Demographics
NPI:1699232207
Name:MILLER, KATHLEEN MARIE
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARIE
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 1:330 WESTERN BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-4383
Mailing Address - Country:US
Mailing Address - Phone:860-547-0306
Mailing Address - Fax:
Practice Address - Street 1:330 WESTERN BLVD STE 102
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-4383
Practice Address - Country:US
Practice Address - Phone:860-547-0306
Practice Address - Fax:860-525-9782
Is Sole Proprietor?:No
Enumeration Date:2019-03-01
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT12-008088363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily