Provider Demographics
NPI:1720352115
Name:MIOTKE, ELIZABETH ANNE (ATC,LAT,PTA)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:ANNE
Last Name:MIOTKE
Suffix:
Gender:F
Credentials:ATC,LAT,PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3923 PRANGE DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-4143
Mailing Address - Country:US
Mailing Address - Phone:765-426-4173
Mailing Address - Fax:
Practice Address - Street 1:3923 PRANGE DR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-4143
Practice Address - Country:US
Practice Address - Phone:765-426-4173
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-02
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06002912A225200000X
IN36000966A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant