Provider Demographics
NPI:1497806962
Name:MILES, JOELLE BOUTWELL (LMT)
Entity Type:Individual
Prefix:MS
First Name:JOELLE
Middle Name:BOUTWELL
Last Name:MILES
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 1:237 W 33RD PL
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-3301
Mailing Address - Country:US
Mailing Address - Phone:850-527-4643
Mailing Address - Fax:
Practice Address - Street 1:647 JENKS AVE STE B2
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-2660
Practice Address - Country:US
Practice Address - Phone:850-522-1788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA31948171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC2540OtherBCBS PROVIDER NUMBER