=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124832688
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MITZIE JOHNSON TAYLOR FNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2025
-----------------------------------------------------
Last Update Date | 02/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3300 S UNIVERSITY DR
-----------------------------------------------------
City | FT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33328-2004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 754-224-9865
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11962 SW PARADISE RIVER RD
-----------------------------------------------------
City | PORT ST LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34987-7762
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 754-224-9865
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 11037479
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------