Provider Demographics
NPI:1184191652
Name:MILLER, LYNN MARIE (ATC)
Entity type:Individual
Prefix:MRS
First Name:LYNN
Middle Name:MARIE
Last Name:MILLER
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:LYNN
Other - Middle Name:MARIE
Other - Last Name:WOLZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:3946 ICE WAY
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-1018
Mailing Address - Country:US
Mailing Address - Phone:260-370-1241
Mailing Address - Fax:
Practice Address - Street 1:3946 ICE WAY
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-1018
Practice Address - Country:US
Practice Address - Phone:260-266-7368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-01
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36002760A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN2543-5138OtherEMERGENCY FIRST RESPONDER