Healthcare Provider Details

I. General information

NPI: 1316859267
Provider Name (Legal Business Name): ATHENA BRONWYN MILLER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2221 MARTIN LUTHER KING JR WAY
OAKLAND CA
94612-1318
US

IV. Provider business mailing address

1421 LOUISIANA ST
VALLEJO CA
94590-4619
US

V. Phone/Fax

Practice location:
  • Phone: 510-267-7887
  • Fax: 510-267-7887
Mailing address:
  • Phone: 510-267-7887
  • Fax: 510-267-7883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number95069731
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: