1598175622 NPI number — KRISTINA KAYE MILLER-GIBSON DOCTORATE OTD

Table of content: KRISTINA KAYE MILLER-GIBSON DOCTORATE OTD (NPI 1598175622)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598175622 NPI number — KRISTINA KAYE MILLER-GIBSON DOCTORATE OTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MILLER-GIBSON
Provider First Name:
KRISTINA
Provider Middle Name:
KAYE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DOCTORATE OTD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ELAM
Provider Other First Name:
KRISTINA
Provider Other Middle Name:
KAYE
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:
1598175622
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/24/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
115 ROCKWOOD LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAZARD
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41701-9415
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-436-5761
Provider Business Mailing Address Fax Number:
606-436-5797

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
305 MORTON BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAZARD
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-435-1741
Provider Business Practice Location Address Fax Number:
606-435-0490
Provider Enumeration Date:
04/29/2014

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: 225X00000X , with the licence number:  131943 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7100417520 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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