Provider Demographics
NPI:1508217530
Name:MILLER, BROOKE JILLIAN
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:JILLIAN
Last Name:MILLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7711 35TH AVE
Mailing Address - Street 2:APT 2L
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-4659
Mailing Address - Country:US
Mailing Address - Phone:845-300-2304
Mailing Address - Fax:
Practice Address - Street 1:7711 35TH AVE
Practice Address - Street 2:APT 2L
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-4659
Practice Address - Country:US
Practice Address - Phone:845-300-2304
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-30
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY30307659363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health