=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700680634
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARMEN JOHNSON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/01/2025
-----------------------------------------------------
Last Update Date | 04/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1010 ARTHUR AVE STE C
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32804-2827
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-332-4845
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4581 POINT LOOK OUT RD
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32808-1735
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-332-4845
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MA103986
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------