Provider Demographics
NPI:1619425352
Name:MILLER, KRYSTINA NICOLE (PT, DPT, ATP)
Entity Type:Individual
Prefix:
First Name:KRYSTINA
Middle Name:NICOLE
Last Name:MILLER
Suffix:
Gender:F
Credentials:PT, DPT, ATP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53919 ATHERTON ST
Mailing Address - Street 2:
Mailing Address - City:NEW BALTIMORE
Mailing Address - State:MI
Mailing Address - Zip Code:48047-5832
Mailing Address - Country:US
Mailing Address - Phone:198-940-0115
Mailing Address - Fax:248-579-0197
Practice Address - Street 1:16009 LEONE DR
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48042-4063
Practice Address - Country:US
Practice Address - Phone:586-232-3644
Practice Address - Fax:248-579-0197
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-12
Last Update Date:2022-09-15
Deactivation Date:2022-08-31
Deactivation Code:
Reactivation Date:2022-09-15
Provider Licenses
StateLicense IDTaxonomies
MI55010156212251N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology