Provider Demographics
NPI:1174525091
Name:JOHNSON, CARRIE LYNN (MD)
Entity type:Individual
Prefix:DR
First Name:CARRIE
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-424-1900
Mailing Address - Fax:239-424-1904
Practice Address - Street 1:1138 COUNTRY CLUB BLVD
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-3027
Practice Address - Country:US
Practice Address - Phone:239-424-1900
Practice Address - Fax:239-424-1904
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2025-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD189072207V00000X
WAMD61550112207V00000X
FLME102875207V00000X
IL036090783207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008052600Medicaid
OH3025372Medicaid
FL119355500Medicaid