Healthcare Provider Details

I. General information

NPI: 1306322656
Provider Name (Legal Business Name): JOHNNIE N BRADLEY-GOODMAN APRN, PMHNP - BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2018
Last Update Date: 06/06/2023
Certification Date: 06/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

84 W LOWDER ST
MACCLENNY FL
32063-2638
US

IV. Provider business mailing address

4300 SW 13TH ST
GAINESVILLE FL
32608-4006
US

V. Phone/Fax

Practice location:
  • Phone: 352-374-5615
  • Fax:
Mailing address:
  • Phone: 352-374-5600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberAPRN9215272
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberARNP9215272
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN9215272
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: