Healthcare Provider Details

I. General information

NPI: 1720352115
Provider Name (Legal Business Name): ELIZABETH ANNE MIOTKE ATC,LAT,PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2012
Last Update Date: 03/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3923 PRANGE DR
LAFAYETTE IN
47905-4143
US

IV. Provider business mailing address

3923 PRANGE DR
LAFAYETTE IN
47905-4143
US

V. Phone/Fax

Practice location:
  • Phone: 765-426-4173
  • Fax:
Mailing address:
  • Phone: 765-426-4173
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number06002912A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36000966A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: