MEDICARE: MIRIAM 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	225200000X	Physical Therapy Assistant	PTA31213	FL

General Provider Information

NPI Number	:	1265268734
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIRIAM JOHNSON

Provider Business Mailing Address
First Line	:	1510 PIONEER WAY
Second Line	:
City	:	ROYAL PALM BEACH
State	:	FL
Zip	:	33411-6250
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1510 PIONEER WAY
Second Line	:
City	:	ROYAL PALM BEACH
State	:	FL
Zip	:	33411-6250
Country	:	US
Telephone Number	:	601-497-3403
Fax Number	:

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

Provider Enumeration Date	:	09/11/2024
Last Update Date	:	09/11/2024

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