Healthcare Provider Details

I. General information

NPI: 1447869938
Provider Name (Legal Business Name): CAROLINE BOUDET JOHNSON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2020
Last Update Date: 12/13/2021
Certification Date: 12/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

92 W MILLER ST
ORLANDO FL
32806-2032
US

IV. Provider business mailing address

92 W MILLER ST
ORLANDO FL
32806-2032
US

V. Phone/Fax

Practice location:
  • Phone: 407-649-9111
  • Fax:
Mailing address:
  • Phone: 407-649-6907
  • Fax: 321-841-5245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License Number11008369
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: