Provider Demographics
NPI:1962670307
Name:MIESMER, TIMOTHY D (ATC)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:D
Last Name:MIESMER
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6048 LAUREN LN
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-6702
Mailing Address - Country:US
Mailing Address - Phone:859-248-5467
Mailing Address - Fax:
Practice Address - Street 1:421 N WOODLAND BLVD UNIT 8317
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32723-8418
Practice Address - Country:US
Practice Address - Phone:859-248-5467
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-20
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYAT1210174400000X
FLAL55652255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No174400000XOther Service ProvidersSpecialist