Healthcare Provider Details

I. General information

NPI: 1285624106
Provider Name (Legal Business Name): JOHNETTA MINER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2005
Last Update Date: 10/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 DARROW PL SUITE 16B
BRONX NY
10475-1802
US

IV. Provider business mailing address

140 DARROW PL SUITE 16B
BRONX NY
10475-1802
US

V. Phone/Fax

Practice location:
  • Phone: 718-379-1290
  • Fax: 718-379-8597
Mailing address:
  • Phone: 718-379-1290
  • Fax: 718-379-8597

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberF420329-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: