Provider Demographics
NPI:1104514785
Name:MILLER, QUASHON JOHN
Entity type:Individual
Prefix:
First Name:QUASHON
Middle Name:JOHN
Last Name:MILLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:QUASHON
Other - Middle Name:
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NUTRITIONIST
Mailing Address - Street 1:1355 E 94TH ST PH PH
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-4803
Mailing Address - Country:US
Mailing Address - Phone:929-620-0470
Mailing Address - Fax:
Practice Address - Street 1:1355 E 94TH ST PH PH
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236-4803
Practice Address - Country:US
Practice Address - Phone:929-620-0470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-01
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4339330133N00000X
NY1037048253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No133N00000XDietary & Nutritional Service ProvidersNutritionist