Healthcare Provider Details

I. General information

NPI: 1679107619
Provider Name (Legal Business Name): ROBERTA JO MILLER APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2020
Last Update Date: 02/28/2020
Certification Date: 02/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9750 FLEMING GRANT RD
MICCO FL
32976-3326
US

IV. Provider business mailing address

9750 FLEMING GRANT RD
MICCO FL
32976-3326
US

V. Phone/Fax

Practice location:
  • Phone: 561-818-7699
  • Fax:
Mailing address:
  • Phone: 561-818-7699
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAPRN11004362
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number11004362
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: