Healthcare Provider Details

I. General information

NPI: 1760217004
Provider Name (Legal Business Name): MS. EVELYN SORPHONIA JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: EVELYN SORPHONIA RICHARDSON

II. Dates (important events)

Enumeration Date: 09/05/2024
Last Update Date: 09/05/2024
Certification Date: 09/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6000 W HIGHWAY 98
PENSACOLA FL
32512-0001
US

IV. Provider business mailing address

6000 W HIGHWAY 98
PENSACOLA FL
32512-8874
US

V. Phone/Fax

Practice location:
  • Phone: 850-505-6784
  • Fax: 850-505-6330
Mailing address:
  • Phone: 850-712-6525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License NumberRN3088062
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: