Healthcare Provider Details

I. General information

NPI: 1770157687
Provider Name (Legal Business Name): GINA NICOLE JOHNSON ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2021
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

773 HIGHWAY 466
LADY LAKE FL
32159-6340
US

IV. Provider business mailing address

601 S HARBOUR ISLAND BLVD STE 200
TAMPA FL
33602-5925
US

V. Phone/Fax

Practice location:
  • Phone: 352-221-9697
  • Fax: 352-259-1132
Mailing address:
  • Phone: 727-322-3439
  • Fax: 800-928-7449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11012991
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: