Healthcare Provider Details

I. General information

NPI: 1639804966
Provider Name (Legal Business Name): NICOLE BRIANA JOHNSON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2022
Last Update Date: 08/29/2024
Certification Date: 08/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 S ORANGE AVE STE 103
ORLANDO FL
32806-2946
US

IV. Provider business mailing address

1717 S ORANGE AVE
ORLANDO FL
32806-2944
US

V. Phone/Fax

Practice location:
  • Phone: 321-841-4344
  • Fax: 321-843-5550
Mailing address:
  • Phone: 321-841-4344
  • Fax: 321-841-4344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11020786
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAPRN11020786
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: