Healthcare Provider Details

I. General information

NPI: 1437704269
Provider Name (Legal Business Name): MARY DAVIS JOHNSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2019
Last Update Date: 08/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4130 SALISBURY RD
JACKSONVILLE FL
32216-8031
US

IV. Provider business mailing address

9438 ARBOR OAK LN
JACKSONVILLE FL
32208-8428
US

V. Phone/Fax

Practice location:
  • Phone: 904-303-3193
  • Fax:
Mailing address:
  • Phone: 904-303-3193
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number2974502
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: