MEDICARE: MRS. KATRENA FAYE JOHNSON SUPPORTED LIVING COA

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	171W00000X	Contractor		FL

General Provider Information

NPI Number	:	1396755773
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KATRENA FAYE JOHNSON SUPPORTED LIVING COA

Provider Business Mailing Address
First Line	:	4500 CRUSADERS WAY
Second Line	:
City	:	GREENWOOD
State	:	FL
Zip	:	32443-6907
Country	:	US
Telephone Number	:	850-209-0195
Fax Number	:	850-592-8195

Provider Business Practice Location Address
First Line	:	4500 CRUSADERS WAY
Second Line	:
City	:	GREENWOOD
State	:	FL
Zip	:	32443-6907
Country	:	US
Telephone Number	:	850-209-0195
Fax Number	:	850-592-8195

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

Provider Enumeration Date	:	08/09/2006
Last Update Date	:	07/08/2007

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