Provider Demographics
NPI:1104381490
Name:JOHNSON, TAISHA (APRN, NP-C)
Entity Type:Individual
Prefix:MS
First Name:TAISHA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:APRN, NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1893 SW KIMBERLY AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-1020
Mailing Address - Country:US
Mailing Address - Phone:772-643-1645
Mailing Address - Fax:319-214-6336
Practice Address - Street 1:1893 SW KIMBERLY AVE
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-1020
Practice Address - Country:US
Practice Address - Phone:772-643-1645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-31
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11000891363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner