Provider Demographics
NPI:1770537524
Name:MILLER, TERESE MARIE (DOM)
Entity type:Individual
Prefix:
First Name:TERESE
Middle Name:MARIE
Last Name:MILLER
Suffix:
Gender:F
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3113 12TH ST N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33704-1907
Mailing Address - Country:US
Mailing Address - Phone:727-821-7771
Mailing Address - Fax:
Practice Address - Street 1:1432 DR MARTIN LUTHER KING JR ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33704-3302
Practice Address - Country:US
Practice Address - Phone:727-821-7771
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL347171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist