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: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1648 AMSTERDAM AVE
NEW YORK NY
10031-6154
US

IV. Provider business mailing address

1648 AMSTERDAM AVE. PMB #30
NEW YORK NY
10031
US

V. Phone/Fax

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

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: