Provider Demographics
NPI:1275503468
Name:JOHNSON, TRACI (FNP-C)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3634 ROGERO RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32277-2556
Mailing Address - Country:US
Mailing Address - Phone:904-744-8414
Mailing Address - Fax:
Practice Address - Street 1:3634 ROGERO RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32277-2556
Practice Address - Country:US
Practice Address - Phone:904-744-8414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 3401792363LF0000X
NC5005191363LF0000X
FL11017334363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAD247ZMedicare PIN