Healthcare Provider Details

I. General information

NPI: 1528475183
Provider Name (Legal Business Name): KORITA JOHNSON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2014
Last Update Date: 07/02/2020
Certification Date: 07/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 45TH ST
WEST PALM BEACH FL
33407-2361
US

IV. Provider business mailing address

800 CLEMATIS ST STE 5-531
WEST PALM BEACH FL
33401-5107
US

V. Phone/Fax

Practice location:
  • Phone: 561-514-5300
  • Fax: 561-514-5538
Mailing address:
  • Phone: 561-671-4043
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberARNP9328169
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: