Healthcare Provider Details

I. General information

NPI: 1700184892
Provider Name (Legal Business Name): JOHANNIE GARCIA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2011
Last Update Date: 09/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 S. WINTERHAWK DR. # 107
ST AUGUSTINE FL
32086-3858
US

IV. Provider business mailing address

367 GIANNA WAY
ST AUGUSTINE FL
32086
US

V. Phone/Fax

Practice location:
  • Phone: 904-826-7886
  • Fax:
Mailing address:
  • Phone: 904-826-7886
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number12653
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: