Provider Demographics
NPI:1366585093
Name:JOHNSON, LORRAINE
Entity type:Individual
Prefix:
First Name:LORRAINE
Middle Name:
Last Name: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 1:1080 WILKINSON RD
Mailing Address - Street 2:
Mailing Address - City:LANTANA
Mailing Address - State:FL
Mailing Address - Zip Code:33462-5960
Mailing Address - Country:US
Mailing Address - Phone:610-703-7425
Mailing Address - Fax:
Practice Address - Street 1:1080 WILKINSON RD
Practice Address - Street 2:
Practice Address - City:LANTANA
Practice Address - State:FL
Practice Address - Zip Code:33462-5960
Practice Address - Country:US
Practice Address - Phone:610-703-7425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN167036367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA43BBCBLMedicare PIN