Provider Demographics
NPI:1346896008
Name:MILES, AMANDA ANNE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:ANNE
Last Name:MILES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:ANNE
Other - Last Name:ALLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13335 SW UTE ST
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-7329
Mailing Address - Country:US
Mailing Address - Phone:503-410-0675
Mailing Address - Fax:
Practice Address - Street 1:6637 SE MILWAUKIE AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-5658
Practice Address - Country:US
Practice Address - Phone:503-410-0675
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-16
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR23114225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR23114OtherALL OTHER NON MEDICARE