Provider Demographics
NPI:1083433551
Name:MCMILLIAN, WENDY RENEE (PTA)
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:RENEE
Last Name:MCMILLIAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:784 FISH LAKE RD
Mailing Address - Street 2:
Mailing Address - City:CANA
Mailing Address - State:VA
Mailing Address - Zip Code:24317-4761
Mailing Address - Country:US
Mailing Address - Phone:276-733-6632
Mailing Address - Fax:
Practice Address - Street 1:1199 HAYES FOREST DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-3377
Practice Address - Country:US
Practice Address - Phone:336-759-1044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-10
Last Update Date:2024-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3759225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant