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General NPI Number Information
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NPI Number | 1083836852
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Entity Type | Individual
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Provider Name | MS. SANDRA Y JOHNSON
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Gender | Female
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Dates
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Enumeration Date | 05/02/2007
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Last Update Date | 12/31/2012
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Provider Practice Location Address
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Address Line | 1800 EDGEWOOD AVE, WEST #164
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City | JACKSONVILLE
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State | FL
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Zip | 32208-5928
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Country | US
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Telephone | 904-318-7993
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Fax |
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Provider Business Mailing Address
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Address Line | 1800 EDGEWOOD AVE W APT 164
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City | JACKSONVILLE
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State | FL
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Zip | 32208-8004
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Country | US
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Telephone | 904-318-7993
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | NH2114
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License Number State | FL
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