Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225200000X | Physical Therapy Assistant | 160006896 | IL |
NPI | 1013572114 |
---|---|
Provider Name | Kendra Miller |
First Address | Springfield, IL 62703-2499 |
Second Address | Springfield, IL 62702-3778 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/05/2019 |
Last Update Date | 03/05/2019 |