Provider Demographics
NPI:1073850459
Name:MILES, ANDREA LYNN (PTA)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:LYNN
Last Name:MILES
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9327 CASTLEWOOD DR SE
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-8573
Mailing Address - Country:US
Mailing Address - Phone:253-720-7804
Mailing Address - Fax:
Practice Address - Street 1:1100 E NELSON RD
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-2360
Practice Address - Country:US
Practice Address - Phone:509-765-6788
Practice Address - Fax:509-766-6757
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-06
Last Update Date:2013-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP160039495225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant