Basic Information
| Provider Information | |||||||||
| NPI: | 1174038319 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | BROOKLYNE | ||||||||
| MiddleName: | TALLENE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | OLSON | ||||||||
| OtherFirstName: | BROOKLYNE | ||||||||
| OtherMiddleName: | TALLENE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CNA, BHT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 323 N MARYLAND PKWY | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891013130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023853330 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 323 N MARYLAND PKWY | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891013130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023853330 | ||||||||
| FaxNumber: | 7022077119 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2017 | ||||||||
| LastUpdateDate: | 12/11/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3747A0650X | Y | Nursing Service Related Providers | Technician | Attendant Care Provider |
No ID Information.