Healthcare Provider Details

I. General information

NPI: 1730179698
Provider Name (Legal Business Name): JON DAVID JOHNSON ARNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 10/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

495 E MAIN ST
LAKE BUTLER FL
32054-1731
US

IV. Provider business mailing address

12049 SW 76TH TER
LAKE BUTLER FL
32054-7724
US

V. Phone/Fax

Practice location:
  • Phone: 386-496-3211
  • Fax: 386-496-1599
Mailing address:
  • Phone: 386-496-4428
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9197452
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: