MEDICARE: MS. SANDRA Y JOHNSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	NH2114	FL

General Provider Information

NPI Number	:	1083836852
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SANDRA Y JOHNSON

Provider Business Mailing Address
First Line	:	1800 EDGEWOOD AVE W APT 164
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32208-8004
Country	:	US
Telephone Number	:	904-318-7993
Fax Number	:

Provider Business Practice Location Address
First Line	:	1800 EDGEWOOD AVE, WEST #164
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32208-5928
Country	:	US
Telephone Number	:	904-318-7993
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/02/2007
Last Update Date	:	12/31/2012

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