Provider Demographics
NPI:1043694011
Name:JOHNSON, RACHEL
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 S ORANGE BLOSSOM TRL
Mailing Address - Street 2:229
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32805-3118
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:750 S ORANGE BLOSSOM TRL
Practice Address - Street 2:229
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32805-3118
Practice Address - Country:US
Practice Address - Phone:386-690-3504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-19
Last Update Date:2015-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010616500Medicaid