Healthcare Provider Details

I. General information

NPI: 1700871662
Provider Name (Legal Business Name): JOHNNA LYNN DETTIS ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2005
Last Update Date: 07/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3487 BROADWAY AVE.
FORT MYERS FL
33901-7213
US

IV. Provider business mailing address

3487 BROADWAY AVE.
FORT MYERS FL
33901-7213
US

V. Phone/Fax

Practice location:
  • Phone: 239-334-9555
  • Fax: 239-334-2832
Mailing address:
  • Phone: 239-334-9555
  • Fax: 239-334-2832

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number1244422
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1244422
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number1244422
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: