1265232524 NPI number — KAITLYN MICHELLE MILLER AG-ACNP

Table of content: KEISHA CHALET WILSON BOURNE HAIR LOSS SPECIALIST (NPI 1508590712)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265232524 NPI number — KAITLYN MICHELLE MILLER AG-ACNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MILLER
Provider First Name:
KAITLYN
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
AG-ACNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TANCINI
Provider Other First Name:
KAITLYN
Provider Other Middle Name:
MICHELLE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1265232524
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11901 THOMAS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREAT FALLS
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22066-1005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
980-622-2570
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1625 N GEORGE MASON DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ARLINGTON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22205-3683
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-558-6491
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/17/2025

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2100X , with the licence number:  024191748 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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