Provider Demographics
NPI:1346016003
Name:BUCHANAN, JOHNNIE L
Entity Type:Individual
Prefix:
First Name:JOHNNIE
Middle Name:L
Last Name:BUCHANAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11522 OTTERS DEN DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32219-5113
Mailing Address - Country:US
Mailing Address - Phone:904-728-8674
Mailing Address - Fax:
Practice Address - Street 1:11522 OTTERS DEN DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32219-5113
Practice Address - Country:US
Practice Address - Phone:904-728-8674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-04
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLB255432741870172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver