Provider Demographics
NPI:1528662509
Name:MILLER, TRACEY S
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:S
Last Name:MILLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18211 KELLY BLVD APT 1632
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75287-4646
Mailing Address - Country:US
Mailing Address - Phone:214-664-5659
Mailing Address - Fax:
Practice Address - Street 1:18211 KELLY BLVD APT 1632
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75287-4646
Practice Address - Country:US
Practice Address - Phone:214-664-5659
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX39417597172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver