Provider Demographics
NPI:1972280592
Name:MILLER, KAYLA
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:
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 1:415 6TH STREET
Mailing Address - Street 2:ATTN: PHYSICIAN SERVICES
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-2424
Mailing Address - Country:US
Mailing Address - Phone:208-750-7462
Mailing Address - Fax:208-750-7467
Practice Address - Street 1:415 6TH ST STE 3C
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-2431
Practice Address - Country:US
Practice Address - Phone:208-750-7300
Practice Address - Fax:208-746-4899
Is Sole Proprietor?:No
Enumeration Date:2023-07-05
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID76807363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1972280592Medicaid
WA2255568Medicaid