=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013552199
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUSTIN LEE MILLER CCNS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/12/2019
-----------------------------------------------------
Last Update Date | 11/12/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1800 NW 10TH AVE UNIT T215
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33136-1018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-294-3095
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3301 NE 1ST AVE APT H2201
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33137-4167
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WC0200X
-----------------------------------------------------
Taxonomy Name | Critical Care Medicine Registered Nurse
-----------------------------------------------------
License Number | 2166722
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 364SA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Clinical Nurse Specialist
-----------------------------------------------------
License Number | 524
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 364S00000X
-----------------------------------------------------
Taxonomy Name | Clinical Nurse Specialist
-----------------------------------------------------
License Number | APRN11004781
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------