Provider Demographics
NPI:1225576010
Name:JOHNSON, WILMA (MS)
Entity Type:Individual
Prefix:
First Name:WILMA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20345 W COUNTRY CLUB DR
Mailing Address - Street 2:TOWN HOUSE - 14
Mailing Address - City:AVENTURA
Mailing Address - State:FL
Mailing Address - Zip Code:33180-1631
Mailing Address - Country:US
Mailing Address - Phone:305-792-2493
Mailing Address - Fax:
Practice Address - Street 1:20345 W COUNTRY CLUB DR
Practice Address - Street 2:TOWN HOUSE - 14
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33180-1631
Practice Address - Country:US
Practice Address - Phone:305-792-2493
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-01
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL682570296Medicaid