Provider Demographics
NPI:1861118358
Name:MILLER, MISTY
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12650 EDINBORO RD
Mailing Address - Street 2:
Mailing Address - City:EDINBORO
Mailing Address - State:PA
Mailing Address - Zip Code:16412-6016
Mailing Address - Country:US
Mailing Address - Phone:814-734-4541
Mailing Address - Fax:
Practice Address - Street 1:12650 EDINBORO RD
Practice Address - Street 2:
Practice Address - City:EDINBORO
Practice Address - State:PA
Practice Address - Zip Code:16412-6016
Practice Address - Country:US
Practice Address - Phone:814-734-4541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-17
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMSG012100225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist