Provider Demographics
NPI:1003786070
Name:JOHNSON PETTIFORD, TRINA
Entity type:Individual
Prefix:
First Name:TRINA
Middle Name:
Last Name:JOHNSON PETTIFORD
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 1:8642 NW 55TH PL
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33067-2808
Mailing Address - Country:US
Mailing Address - Phone:954-638-7096
Mailing Address - Fax:
Practice Address - Street 1:8642 NW 55TH PL
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33067-2808
Practice Address - Country:US
Practice Address - Phone:954-638-7096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-11-06
Last Update Date:2025-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9244404364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGroup - Multi-Specialty