Provider Demographics
NPI:1619214681
Name:MILLER, TRACEY REYNEE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:REYNEE
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 1:1130 NANTUCKET RD
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34293-5316
Mailing Address - Country:US
Mailing Address - Phone:309-945-5829
Mailing Address - Fax:
Practice Address - Street 1:1130 NANTUCKET RD
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34293
Practice Address - Country:US
Practice Address - Phone:309-945-5829
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-11
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA22880225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant