Healthcare Provider Details

I. General information

NPI: 1316999501
Provider Name (Legal Business Name): ANGELA LYNN MILLER ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 04/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 17TH AVE E
ALEXANDRIA MN
56308-3798
US

IV. Provider business mailing address

111 17TH AVE E
ALEXANDRIA MN
56308-3798
US

V. Phone/Fax

Practice location:
  • Phone: 320-762-1511
  • Fax: 320-762-6471
Mailing address:
  • Phone: 320-762-1511
  • Fax: 320-762-6471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096-001861
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: