Provider Demographics
NPI:1437704269
Name:JOHNSON, MARY DAVIS (RN)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:DAVIS
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9438 ARBOR OAK LN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32208-8428
Mailing Address - Country:US
Mailing Address - Phone:904-303-3193
Mailing Address - Fax:
Practice Address - Street 1:4130 SALISBURY RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-8031
Practice Address - Country:US
Practice Address - Phone:904-303-3193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-08
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2974502163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health