=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417433095
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMY MILLER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2018
-----------------------------------------------------
Last Update Date | 07/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4761 STATE ROUTE 29
-----------------------------------------------------
City | CELINA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45822-8216
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-584-1000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4761 STATE ROUTE 29
-----------------------------------------------------
City | CELINA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45822-8216
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-584-1000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 405300000X
-----------------------------------------------------
Taxonomy Name | Prevention Professional
-----------------------------------------------------
License Number | OCPSA.161355
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------