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General NPI Number Information
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NPI Number | 1811726250
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Entity Type | Individual
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Provider Name | MACKENZIE ANN MILLER ATC
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Gender | Female
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Dates
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Enumeration Date | 08/01/2024
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Last Update Date | 08/01/2024
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Provider Practice Location Address
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Address Line | 1 COLLEGE HL
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City | CANTON
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State | MO
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Zip | 63435-1257
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Country | US
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Telephone | 573-333-7561
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Fax |
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Provider Business Mailing Address
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Address Line | 21034 GINKGO ST
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City | LEWISTOWN
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State | MO
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Zip | 63452-2406
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Country | US
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Telephone | 605-999-3612
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 2024021221
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License Number State | MO
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