1619425352 NPI number — KRYSTINA NICOLE MILLER PT, DPT, ATP

Table of content: KRYSTINA NICOLE MILLER PT, DPT, ATP (NPI 1619425352)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619425352 NPI number — KRYSTINA NICOLE MILLER PT, DPT, ATP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MILLER
Provider First Name:
KRYSTINA
Provider Middle Name:
NICOLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT, ATP
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:
1619425352
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/15/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
08/31/2022
NPI Reactivation Date:
09/15/2022

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
53919 ATHERTON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW BALTIMORE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48047-5832
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
198-940-0115
Provider Business Mailing Address Fax Number:
248-579-0197

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16009 LEONE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MACOMB
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48042-4063
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-232-3644
Provider Business Practice Location Address Fax Number:
248-579-0197
Provider Enumeration Date:
09/12/2016

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: 2251N0400X , with the licence number:  5501015621 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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