Provider Demographics
NPI:1750345898
Name:JOHNSON, MARY (ARNP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 SOUTH BLVD E
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33837-7542
Mailing Address - Country:US
Mailing Address - Phone:321-677-0531
Mailing Address - Fax:321-677-0537
Practice Address - Street 1:7575 OSCEOLA POLK LINE RD
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33896-9112
Practice Address - Country:US
Practice Address - Phone:321-677-0531
Practice Address - Fax:321-677-0537
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1466102363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL304941800Medicaid
FLU0125ZMedicare ID - Type UnspecifiedMEDICARE PROVIDER #
FL304941800Medicaid