Provider Demographics
NPI:1467661652
Name:MILLER, AUDREA ANN (PTA)
Entity Type:Individual
Prefix:MS
First Name:AUDREA
Middle Name:ANN
Last Name:MILLER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13951 W. CO. RD. 650 S.
Mailing Address - Street 2:
Mailing Address - City:DALEVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47334
Mailing Address - Country:US
Mailing Address - Phone:765-378-1449
Mailing Address - Fax:
Practice Address - Street 1:910 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47320-1530
Practice Address - Country:US
Practice Address - Phone:765-789-4423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99026851A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant