Provider Demographics
NPI:1689188799
Name:MILLER, MISTI MICHELLE (LMT MMP)
Entity Type:Individual
Prefix:
First Name:MISTI
Middle Name:MICHELLE
Last Name:MILLER
Suffix:
Gender:F
Credentials:LMT MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:568 W TELEGRAPH ST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:UT
Mailing Address - Zip Code:84780-1205
Mailing Address - Country:US
Mailing Address - Phone:702-378-2841
Mailing Address - Fax:435-627-0781
Practice Address - Street 1:568 W TELEGRAPH ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:UT
Practice Address - Zip Code:84780-1205
Practice Address - Country:US
Practice Address - Phone:702-378-2841
Practice Address - Fax:435-627-0781
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-28
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9674482-4701225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT9674482-4701OtherSTATE OF UTAH DEPARTMENT OF COMMERCE