1841801099 NPI number — MRS. SHANNON KELLY MILLER RDH

Table of content: MRS. SHANNON KELLY MILLER RDH (NPI 1841801099)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841801099 NPI number — MRS. SHANNON KELLY MILLER RDH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MILLER
Provider First Name:
SHANNON
Provider Middle Name:
KELLY
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RDH
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:
1841801099
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/12/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 129 OQUAWKA IL 61469
Provider Second Line Business Mailing Address:
111 S. 10TH ST. OQUAWKA IL 61469
Provider Business Mailing Address City Name:
OQUAWKA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61469
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-759-6644
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1204 HWY 164 E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OQUAWKA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61469
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-867-2770
Provider Business Practice Location Address Fax Number:
309-867-3205
Provider Enumeration Date:
08/12/2020

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: 124Q00000X , with the licence number:  020.011534 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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