MEDICARE: GLENDORA WHITLOW 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	224Z00000X	Occupational Therapy Assistant	16893	FL

General Provider Information

NPI Number	:	1780142323
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLENDORA WHITLOW JOHNSON

Provider Business Mailing Address
First Line	:	423 HIGHWAY 466 APT 23203
Second Line	:
City	:	LADY LAKE
State	:	FL
Zip	:	32159-6315
Country	:	US
Telephone Number	:	352-978-3003
Fax Number	:

Provider Business Practice Location Address
First Line	:	423 HIGHWAY 466 APT 23203
Second Line	:
City	:	LADY LAKE
State	:	FL
Zip	:	32159-6315
Country	:	US
Telephone Number	:	352-978-3003
Fax Number	:

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

Provider Enumeration Date	:	03/02/2019
Last Update Date	:	03/02/2019

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