Provider Demographics
NPI:1346993896
Name:DRAGONFLY SUPPORT COORDINATION
Entity Type:Organization
Organization Name:DRAGONFLY SUPPORT COORDINATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:WAIVER SUPPORT COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:SHERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-965-5418
Mailing Address - Street 1:3216 NW 47TH PL
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-1100
Mailing Address - Country:US
Mailing Address - Phone:352-262-7672
Mailing Address - Fax:
Practice Address - Street 1:3216 NW 47TH PL
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-1100
Practice Address - Country:US
Practice Address - Phone:352-262-7672
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-03
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110051800Medicaid