Provider Demographics
NPI:1679334601
Name:MILLER, LAURA SHELBY (ATC)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:SHELBY
Last Name:MILLER
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14358 WILLIAMSBURG DR
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-3418
Mailing Address - Country:US
Mailing Address - Phone:337-356-7031
Mailing Address - Fax:
Practice Address - Street 1:14358 WILLIAMSBURG DR
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3418
Practice Address - Country:US
Practice Address - Phone:337-356-7031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-17
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS07612255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer