Provider Demographics
NPI:1992292171
Name:MILLER, MADDISON
Entity type:Individual
Prefix:
First Name:MADDISON
Middle Name:
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 1:1491 LAMPLITE DR
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:PA
Mailing Address - Zip Code:17315-2600
Mailing Address - Country:US
Mailing Address - Phone:717-487-6262
Mailing Address - Fax:
Practice Address - Street 1:1491 LAMPLITE DR
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:PA
Practice Address - Zip Code:17315-2600
Practice Address - Country:US
Practice Address - Phone:717-487-6262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-13
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA2255A2300X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer