Provider Demographics
NPI:1437880325
Name:JOHNSON, LYLLIE CHRISTINE MC BRIDE (MS, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:LYLLIE
Middle Name:CHRISTINE MC BRIDE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3384 SUNCOAST PLAINS DR
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:FL
Mailing Address - Zip Code:33556-2935
Mailing Address - Country:US
Mailing Address - Phone:203-733-6035
Mailing Address - Fax:
Practice Address - Street 1:13837 CIRCA CROSSING DR
Practice Address - Street 2:
Practice Address - City:LITHIA
Practice Address - State:FL
Practice Address - Zip Code:33547-4382
Practice Address - Country:US
Practice Address - Phone:203-733-6035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-21
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20000514142255A2300X
FL66762081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer