MEDICARE: OLIVIA ANNE 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	3279	TN

General Provider Information

NPI Number	:	1528819166
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OLIVIA ANNE MILLER LAT ATC

Provider Business Mailing Address
First Line	:	550 COILE RD
Second Line	:
City	:	JEFFERSON CTY
State	:	TN
Zip	:	37760-4101
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3925 ADKISSON DR NW APT 2233
Second Line	:
City	:	CLEVELAND
State	:	TN
Zip	:	37312-3168
Country	:	US
Telephone Number	:	865-964-8135
Fax Number	:

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

Provider Enumeration Date	:	04/01/2024
Last Update Date	:	04/03/2025

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