Healthcare Provider Details

I. General information

NPI: 1063338838
Provider Name (Legal Business Name): CLINTINA JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CLINTINA ROGERS

II. Dates (important events)

Enumeration Date: 06/26/2026
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4576 WOODBINE RD
PACE FL
32571-8705
US

IV. Provider business mailing address

4576 WOODBINE RD
PACE FL
32571-8705
US

V. Phone/Fax

Practice location:
  • Phone: 786-602-7029
  • Fax:
Mailing address:
  • Phone: 786-602-7029
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9647275
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: