MEDICARE: GABRIELLE ELIZABETH MILLER LAT, ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	AT005670	OH

General Provider Information

NPI Number	:	1083189641
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GABRIELLE ELIZABETH MILLER LAT, ATC

Provider Business Mailing Address
First Line	:	30220 GEBHART PL
Second Line	:
City	:	WILLOWICK
State	:	OH
Zip	:	44095-4915
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2121 EUCLID AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44115-2214
Country	:	US
Telephone Number	:	216-687-4806
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/10/2018
Last Update Date	:	10/10/2018

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