Provider Demographics
NPI:1093403800
Name:MILLER, TRACY LYNN
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:LYNN
Last Name:MILLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15050 S SPRINGDALE AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLEFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44062-9211
Mailing Address - Country:US
Mailing Address - Phone:440-632-0530
Mailing Address - Fax:440-632-0537
Practice Address - Street 1:15050 S SPRINGDALE AVE
Practice Address - Street 2:
Practice Address - City:MIDDLEFIELD
Practice Address - State:OH
Practice Address - Zip Code:44062-9211
Practice Address - Country:US
Practice Address - Phone:440-632-0530
Practice Address - Fax:440-632-0530
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-28
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSC6183156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician