Healthcare Provider Details

I. General information

NPI: 1376100040
Provider Name (Legal Business Name): CHRISTINE NICOLE MILLER PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2019
Last Update Date: 05/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 S ORLANDO AVE
WINTER PARK FL
32789-7102
US

IV. Provider business mailing address

811 S ORLANDO AVE
WINTER PARK FL
32789-7102
US

V. Phone/Fax

Practice location:
  • Phone: 407-539-1792
  • Fax: 407-539-2228
Mailing address:
  • Phone: 407-539-1792
  • Fax: 407-539-2228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA23291
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: