Provider Demographics
NPI:1396523080
Name:MILLER, TRACY LYNNE (MT)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNNE
Last Name:MILLER
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:374 SUMMER LN
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55117-2335
Mailing Address - Country:US
Mailing Address - Phone:505-501-0687
Mailing Address - Fax:
Practice Address - Street 1:1740 WEIR DR STE 24
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-2282
Practice Address - Country:US
Practice Address - Phone:651-232-6830
Practice Address - Fax:651-702-2636
Is Sole Proprietor?:No
Enumeration Date:2023-09-15
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM8415225700000X
225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist