Provider Demographics
NPI:1881136935
Name:MILLER, AMANDA (LAC)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 VIN ROSE WAY
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95337-6831
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:450 VIN ROSE WAY
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95337-6831
Practice Address - Country:US
Practice Address - Phone:209-456-2206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-07
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 17358171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist