Provider Demographics
NPI:1942017561
Name:JOHNSON, DIANTHA LUCRETIA (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:DIANTHA
Middle Name:LUCRETIA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8140 SW 29TH ST
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-6712
Mailing Address - Country:US
Mailing Address - Phone:954-854-5220
Mailing Address - Fax:
Practice Address - Street 1:8140 SW 29TH ST
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33025-6712
Practice Address - Country:US
Practice Address - Phone:954-854-5220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-17
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11036737363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily