Provider Demographics
NPI:1164940805
Name:MILLER, CARLY
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
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 1:657 POTTER ST
Mailing Address - Street 2:
Mailing Address - City:TIFFIN
Mailing Address - State:IA
Mailing Address - Zip Code:52340-9414
Mailing Address - Country:US
Mailing Address - Phone:319-541-1522
Mailing Address - Fax:
Practice Address - Street 1:657 POTTER ST
Practice Address - Street 2:
Practice Address - City:TIFFIN
Practice Address - State:IA
Practice Address - Zip Code:52340-9414
Practice Address - Country:US
Practice Address - Phone:319-541-1522
Practice Address - Fax:319-541-1522
Is Sole Proprietor?:No
Enumeration Date:2017-09-01
Last Update Date:2017-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer