Provider Demographics
NPI:1467684985
Name:MACKINNON, JOHANNA V (RN)
Entity Type:Individual
Prefix:MRS
First Name:JOHANNA
Middle Name:V
Last Name:MACKINNON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MISS
Other - First Name:LETICIA
Other - Middle Name:JOHANNA
Other - Last Name:VIAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2400 MICCOSUKEE RD
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-5314
Mailing Address - Country:US
Mailing Address - Phone:850-942-4706
Mailing Address - Fax:
Practice Address - Street 1:2400 MICCOSUKEE RD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-5314
Practice Address - Country:US
Practice Address - Phone:850-942-4706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-17
Last Update Date:2009-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN3067342163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care