MEDICARE: SAMANTHIA JOHNSON LPN

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	164W00000X	Licensed Practical Nurse	PN5228272	FL

General Provider Information

NPI Number	:	1851122956
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHIA JOHNSON LPN

Provider Business Mailing Address
First Line	:	4650 LIPSCOMB ST NE STE 14
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32905-2997
Country	:	US
Telephone Number	:	321-527-4019
Fax Number	:

Provider Business Practice Location Address
First Line	:	4650 LIPSCOMB ST NE STE 14
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32905-2997
Country	:	US
Telephone Number	:	321-527-4019
Fax Number	:

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

Provider Enumeration Date	:	08/09/2024
Last Update Date	:	08/09/2024

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