Healthcare Provider Details

I. General information

NPI: 1710130356
Provider Name (Legal Business Name): MRS. ANDREA JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2008
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7185 ANN CATHERINE CT
PORT SAINT JOHN FL
32927-3055
US

IV. Provider business mailing address

7185 ANN CATHERINE CT
PORT SAINT JOHN FL
32927-3055
US

V. Phone/Fax

Practice location:
  • Phone: 954-829-2341
  • Fax:
Mailing address:
  • Phone: 954-829-2341
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSZ4669
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP007386
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA12868
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: