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General NPI Number Information
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NPI Number | 1942633276
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Entity Type | Individual
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Provider Name | BRENDA LEE JOHNSON 09/28/1965
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Gender | Female
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Dates
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Enumeration Date | 08/09/2013
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Last Update Date | 10/08/2014
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Provider Practice Location Address
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Address Line | 308 SW. SHELBY AVENUE
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City | MADISON
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State | FL
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Zip | 32340-2334
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Country | US
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Telephone | 850-973-0591
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Fax |
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Provider Business Mailing Address
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Address Line | 308 SW. SHELBY AVENUE
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City | MADISON
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State | FL
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Zip | 32340-2334
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Country | US
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Telephone | 850-973-0591
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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 | 253J00000X
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Taxonomy Name | Foster Care Agency
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License Number | 008047400
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License Number State | FL
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