Healthcare Provider Details

I. General information

NPI: 1013552199
Provider Name (Legal Business Name): JUSTIN LEE MILLER CCNS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2019
Last Update Date: 11/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 NW 10TH AVE UNIT T215
MIAMI FL
33136-1018
US

IV. Provider business mailing address

3301 NE 1ST AVE APT H2201
MIAMI FL
33137-4167
US

V. Phone/Fax

Practice location:
  • Phone: 808-294-3095
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number2166722
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number524
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License NumberAPRN11004781
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: