Provider Demographics
NPI:1558380774
Name:MCMILLAN, CONNIE J (PT)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:J
Last Name:MCMILLAN
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 1:6631 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609-4355
Mailing Address - Country:US
Mailing Address - Phone:307-268-9904
Mailing Address - Fax:307-268-9907
Practice Address - Street 1:6631 E 2ND ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609-4355
Practice Address - Country:US
Practice Address - Phone:307-268-9904
Practice Address - Fax:307-268-9907
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2010-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT-057225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY114651300Medicaid
WY114651300Medicaid