Provider Demographics
NPI:1083836852
Name:JOHNSON, SANDRA Y
Entity Type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:Y
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 1:1800 EDGEWOOD AVE W APT 164
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32208-8004
Mailing Address - Country:US
Mailing Address - Phone:904-318-7993
Mailing Address - Fax:
Practice Address - Street 1:1800 EDGEWOOD AVE, WEST #164
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32208-5928
Practice Address - Country:US
Practice Address - Phone:904-318-7993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2012-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLNH2114174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist