Healthcare Provider Details

I. General information

NPI: 1306215157
Provider Name (Legal Business Name): AMY MILLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2015
Last Update Date: 03/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2046 JONATHAN CREEK RD
ARTHUR IL
61911-6108
US

IV. Provider business mailing address

2046 JONATHAN CREEK RD
ARTHUR IL
61911-6108
US

V. Phone/Fax

Practice location:
  • Phone: 217-962-0614
  • Fax:
Mailing address:
  • Phone: 217-962-0614
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberLMT 8092
License Number StateMT
# 2
Primary TaxonomyY
Taxonomy Code405300000X
TaxonomyPrevention Professional
License Number778931277
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: