Provider Demographics
NPI: | 1013552199 |
---|---|
Name: | MILLER, JUSTIN LEE (CCNS) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | JUSTIN |
Middle Name: | LEE |
Last Name: | MILLER |
Suffix: | |
Gender: | M |
Credentials: | CCNS |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 3301 NE 1ST AVE APT H2201 |
Mailing Address - Street 2: | |
Mailing Address - City: | MIAMI |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 33137-4167 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1800 NW 10TH AVE UNIT T215 |
Practice Address - Street 2: | |
Practice Address - City: | MIAMI |
Practice Address - State: | FL |
Practice Address - Zip Code: | 33136-1018 |
Practice Address - Country: | US |
Practice Address - Phone: | 808-294-3095 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2019-11-12 |
Last Update Date: | 2019-11-12 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MN | 2166722 | 163WC0200X |
MN | 524 | 364SA2200X |
FL | APRN11004781 | 364S00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 364S00000X | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | |
No | 163WC0200X | Nursing Service Providers | Registered Nurse | Critical Care Medicine |
No | 364SA2200X | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Adult Health |