Provider Demographics
NPI:1295859130
Name:MILLER, MARY ANN (LMP)
Entity Type:Individual
Prefix:MISS
First Name:MARY
Middle Name:ANN
Last Name:MILLER
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1267
Mailing Address - Street 2:
Mailing Address - City:EPHRATA
Mailing Address - State:WA
Mailing Address - Zip Code:98823-1699
Mailing Address - Country:US
Mailing Address - Phone:360-286-8151
Mailing Address - Fax:
Practice Address - Street 1:318 MAIN AVENUE EAST
Practice Address - Street 2:
Practice Address - City:SOAP LAKE
Practice Address - State:WA
Practice Address - Zip Code:98851
Practice Address - Country:US
Practice Address - Phone:509-246-1660
Practice Address - Fax:509-246-1660
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-17
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00016970225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA204320615OtherAXIA HEALTH NETWORK