Provider Demographics
NPI:1770224065
Name:MILLER JOHNSON, TARA KORTNEY
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:KORTNEY
Last Name:MILLER JOHNSON
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 1:120 NASSAU ST APT 18A
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-1491
Mailing Address - Country:US
Mailing Address - Phone:818-272-9511
Mailing Address - Fax:
Practice Address - Street 1:18 W BLACKWELL ST
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:NJ
Practice Address - Zip Code:07801-3841
Practice Address - Country:US
Practice Address - Phone:973-328-3344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-02
Last Update Date:2022-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program