Provider Demographics
NPI:1376950550
Name:MILLER, NICOLE (LMT)
Entity Type:Individual
Prefix:MISS
First Name:NICOLE
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2137 W CORNELIA AVE APT 2W
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-6130
Mailing Address - Country:US
Mailing Address - Phone:773-557-2363
Mailing Address - Fax:
Practice Address - Street 1:5215 N RAVENSWOOD AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-1668
Practice Address - Country:US
Practice Address - Phone:773-878-7330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-19
Last Update Date:2014-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.009190225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist