Provider Demographics
NPI:1821151044
Name:MILLER, AMANDA MARIE (PTA, LMP, LMT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:MILLER
Suffix:
Gender:F
Credentials:PTA, LMP, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 W PERUGIA ST APT V308
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-4896
Mailing Address - Country:US
Mailing Address - Phone:509-999-1752
Mailing Address - Fax:
Practice Address - Street 1:3800 W PERUGIA ST APT V308
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-4896
Practice Address - Country:US
Practice Address - Phone:509-999-1752
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00022628225700000X
WAP160041285225200000X
IDMAS2825225700000X
AZMT21298225700000X
IDPTA386225200000X
AZ8776A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist