Provider Demographics
NPI:1376300079
Name:MILLER, GRACELYNN GENE (PT, DPT)
Entity type:Individual
Prefix:
First Name:GRACELYNN
Middle Name:GENE
Last Name:MILLER
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2003 W ATKINSON RD
Mailing Address - Street 2:
Mailing Address - City:OTHELLO
Mailing Address - State:WA
Mailing Address - Zip Code:99344-9744
Mailing Address - Country:US
Mailing Address - Phone:509-954-9499
Mailing Address - Fax:
Practice Address - Street 1:1310 W STEWART DR STE 404
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3855
Practice Address - Country:US
Practice Address - Phone:714-707-6466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-29
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT61526686225100000X
CA305768225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist