1508152489 NPI number — MS. HOLLY ANN JOHNSON LICENSED BY FLORIDA

Table of content: MS. HOLLY ANN JOHNSON LICENSED BY FLORIDA (NPI 1508152489)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508152489 NPI number — MS. HOLLY ANN JOHNSON LICENSED BY FLORIDA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
HOLLY
Provider Middle Name:
ANN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LICENSED BY FLORIDA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MURDOCK
Provider Other First Name:
HOLLY
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
HIS
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1508152489
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/24/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
506 TOMPKINS ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INVERNESS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34450-4141
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-423-1799
Provider Business Mailing Address Fax Number:
352-306-6841

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
506 TOMPKINS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INVERNESS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34450-4141
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-423-1799
Provider Business Practice Location Address Fax Number:
352-306-6841
Provider Enumeration Date:
06/20/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 237700000X , with the licence number:  2643 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 237700000X , with the licence number: AS5705 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0050404 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 119795500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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