Healthcare Provider Details

I. General information

NPI: 1942020151
Provider Name (Legal Business Name): BREANA JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2024
Last Update Date: 10/12/2024
Certification Date: 10/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

332 FORT EDWARD DR
ARLINGTON TX
76002-4498
US

IV. Provider business mailing address

332 FORT EDWARD DR
ARLINGTON TX
76002-4498
US

V. Phone/Fax

Practice location:
  • Phone: 904-962-1518
  • Fax:
Mailing address:
  • Phone: 904-962-1518
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number1177822
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: