MEDICARE: MICHELLE JOHNSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	PN 5166406	FL

General Provider Information

NPI Number	:	1912194051
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE JOHNSON

Provider Business Mailing Address
First Line	:	5532 NW E TORINO PKWY
Second Line	:	APT 212
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34986-4622
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5532 NW E TORINO PKWY
Second Line	:	APT 212
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34986-4622
Country	:	US
Telephone Number	:	772-626-7172
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/03/2007
Last Update Date	:	10/03/2007

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