Provider Demographics
NPI:1053781369
Name:MILLEA, MAKAYLA
Entity type:Individual
Prefix:
First Name:MAKAYLA
Middle Name:
Last Name:MILLEA
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 1:111 SALE BARN RD STE 3
Mailing Address - Street 2:
Mailing Address - City:STORM LAKE
Mailing Address - State:IA
Mailing Address - Zip Code:50588-7341
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 SALE BARN RD STE 3
Practice Address - Street 2:
Practice Address - City:STORM LAKE
Practice Address - State:IA
Practice Address - Zip Code:50588-7341
Practice Address - Country:US
Practice Address - Phone:712-213-1500
Practice Address - Fax:712-213-1502
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-29
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA073605225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist