Provider Demographics
NPI:1770313066
Name:MILLER, MICHELLE MAE (LAC)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MAE
Last Name:MILLER
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:SHELLY
Other - Middle Name:MAE
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LAC
Mailing Address - Street 1:172 E MERRITT ST STE C
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-2027
Mailing Address - Country:US
Mailing Address - Phone:928-642-5382
Mailing Address - Fax:928-224-7252
Practice Address - Street 1:172 E MERRITT ST STE C
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-2027
Practice Address - Country:US
Practice Address - Phone:928-642-5382
Practice Address - Fax:928-224-7252
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-02
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-012228171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist