Healthcare Provider Details

I. General information

NPI: 1699002337
Provider Name (Legal Business Name): JESSIE VANDERVEER MILLER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2009
Last Update Date: 01/10/2023
Certification Date: 01/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 E ROLLINS ST
ORLANDO FL
32803-1248
US

IV. Provider business mailing address

601 E ROLLINS ST
ORLANDO FL
32803-1248
US

V. Phone/Fax

Practice location:
  • Phone: 407-975-0412
  • Fax:
Mailing address:
  • Phone: 407-975-0412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9105829
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1977
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9105829
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: