Provider Demographics
NPI:1346221389
Name:MILLER, CONNIE S (PT)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:S
Last Name:MILLER
Suffix:
Gender:F
Credentials:PT
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 156
Mailing Address - Street 2:
Mailing Address - City:CARLTON
Mailing Address - State:WA
Mailing Address - Zip Code:98814-0156
Mailing Address - Country:US
Mailing Address - Phone:509-997-0248
Mailing Address - Fax:
Practice Address - Street 1:123 E JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:CHELAN
Practice Address - State:WA
Practice Address - Zip Code:98816-0006
Practice Address - Country:US
Practice Address - Phone:509-682-4713
Practice Address - Fax:509-682-3218
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA025205 PT00002409225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA33461OtherL&I ID
WA8335598Medicaid
WAGAB33829Medicare ID - Type UnspecifiedPERSONAL MEDICARE ID