Provider Demographics
NPI:1942455324
Name:MILLER, NICOLE ANN (PT)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:ANN
Last Name:MILLER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:NICOLE
Other - Middle Name:ANN
Other - Last Name:LAFOUNTAINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:3205 GOLDENEYE LN
Mailing Address - Street 2:
Mailing Address - City:WOLVERINE LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48390-5459
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5336 KRISTI LN
Practice Address - Street 2:
Practice Address - City:COMMERCE TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48382-3358
Practice Address - Country:US
Practice Address - Phone:248-860-2542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-26
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501008068225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist