Provider Demographics
NPI:1457844268
Name:STUBBS, JOHNETTA LARESA
Entity Type:Individual
Prefix:MS
First Name:JOHNETTA
Middle Name:LARESA
Last Name:STUBBS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1674 HAWTHORNE PL
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-8663
Mailing Address - Country:US
Mailing Address - Phone:561-567-2969
Mailing Address - Fax:
Practice Address - Street 1:1674 HAWTHORNE PL
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-8663
Practice Address - Country:US
Practice Address - Phone:561-567-2969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-07
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty