Provider Demographics
NPI:1669626974
Name:MILLER, RENAE K (LMP)
Entity Type:Individual
Prefix:MS
First Name:RENAE
Middle Name:K
Last Name:MILLER
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 NE 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:MILTON FREEWATER
Mailing Address - State:OR
Mailing Address - Zip Code:97862-1641
Mailing Address - Country:US
Mailing Address - Phone:509-629-1149
Mailing Address - Fax:888-508-8357
Practice Address - Street 1:800 SPRAGUE AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362
Practice Address - Country:US
Practice Address - Phone:509-629-1149
Practice Address - Fax:888-508-8357
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-13
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00015879225700000X
OR5373225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist