Healthcare Provider Details

I. General information

NPI: 1700870631
Provider Name (Legal Business Name): VICKY C JOHNSON CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 03/24/2023
Certification Date: 03/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1806 S OSPREY AVE
SARASOTA FL
34239-3613
US

IV. Provider business mailing address

3526 TREBOR LN
SARASOTA FL
34235-6908
US

V. Phone/Fax

Practice location:
  • Phone: 239-470-1674
  • Fax:
Mailing address:
  • Phone: 239-470-1674
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number932572
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: