Healthcare Provider Details

I. General information

NPI: 1053136739
Provider Name (Legal Business Name): KERRI PETRO MILLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2024
Last Update Date: 11/18/2024
Certification Date: 11/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22620 SE 4TH ST STE 240
SAMMAMISH WA
98074-7375
US

IV. Provider business mailing address

3050 206TH WAY NE
SAMMAMISH WA
98074-4370
US

V. Phone/Fax

Practice location:
  • Phone: 425-200-0054
  • Fax: 425-636-3272
Mailing address:
  • Phone: 770-330-7642
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT00008058
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: