Healthcare Provider Details

I. General information

NPI: 1710191796
Provider Name (Legal Business Name): DELORES DIANNE MILLER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 9TH
PRIEST RIVER ID
83856
US

IV. Provider business mailing address

37012 N BLANCHARD CREEK RD
NEWPORT WA
99156-9410
US

V. Phone/Fax

Practice location:
  • Phone: 208-448-2808
  • Fax: 208-448-2809
Mailing address:
  • Phone: 509-447-5901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00016213
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: