Healthcare Provider Details

I. General information

NPI: 1740931948
Provider Name (Legal Business Name): GLORIA JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2022
Last Update Date: 10/15/2024
Certification Date: 10/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2415 N ORANGE AVE STE 502
ORLANDO FL
32804-5503
US

IV. Provider business mailing address

9535 VERONA LAKES BLVD
BOYNTON BEACH FL
33472-2759
US

V. Phone/Fax

Practice location:
  • Phone: 407-303-2805
  • Fax: 407-303-2801
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9119046
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: