Provider Demographics
NPI:1639421712
Name:MILLER, TERI M (MS, RD, CDE)
Entity Type:Individual
Prefix:
First Name:TERI
Middle Name:M
Last Name:MILLER
Suffix:
Gender:F
Credentials:MS, RD, CDE
Other - Prefix:
Other - First Name:TERI
Other - Middle Name:
Other - Last Name:BOND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1919 E THOMAS RD
Mailing Address - Street 2:BUILDING 2108, SUITE 101
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-7710
Mailing Address - Country:US
Mailing Address - Phone:602-512-8030
Mailing Address - Fax:602-512-8161
Practice Address - Street 1:1919 E THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-7710
Practice Address - Country:US
Practice Address - Phone:602-933-0935
Practice Address - Fax:602-933-0610
Is Sole Proprietor?:No
Enumeration Date:2012-10-12
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ713007133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ753866Medicaid