=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518662162
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERIC MARCELLUS JOHNSON
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2023
-----------------------------------------------------
Last Update Date | 04/03/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4620 N STATE ROAD 7
-----------------------------------------------------
City | LAUDERDALE LAKES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33319-5884
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-501-7232
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3931 NW 108TH AVE
-----------------------------------------------------
City | CORAL SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33065-2709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-501-7232
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 374J00000X
-----------------------------------------------------
Taxonomy Name | Doula
-----------------------------------------------------
License Number | 202303041
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------