1760356158 NPI number — KIMBERLY JEANNE MILLER LADC SUPERVISOR

Table of content: KIMBERLY JEANNE MILLER LADC SUPERVISOR (NPI 1760356158)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760356158 NPI number — KIMBERLY JEANNE MILLER LADC SUPERVISOR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MILLER
Provider First Name:
KIMBERLY
Provider Middle Name:
JEANNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LADC SUPERVISOR
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1760356158
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/30/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5108 W 74TH ST STE 776
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDINA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55439-2464
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-208-8202
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1624 HARMON PL STE 203
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55403-1902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-208-8202
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/30/2025

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: 101YA0400X , with the licence number:  306301 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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