Healthcare Provider Details

I. General information

NPI: 1780230797
Provider Name (Legal Business Name): LATARSHA MILES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2019
Last Update Date: 08/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 PRUDENTIAL DR
JACKSONVILLE FL
32207-8202
US

IV. Provider business mailing address

800 PRUDENTIAL DR
JACKSONVILLE FL
32207-8202
US

V. Phone/Fax

Practice location:
  • Phone: 904-202-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number9518005
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: