Provider Demographics
NPI:1508806571
Name:SMITH, JOHNNA (ARNP)
Entity Type:Individual
Prefix:
First Name:JOHNNA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4930
Mailing Address - Street 2:DEPT. 102
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77210-4930
Mailing Address - Country:US
Mailing Address - Phone:941-917-1668
Mailing Address - Fax:941-917-4273
Practice Address - Street 1:1700 S TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-3509
Practice Address - Country:US
Practice Address - Phone:941-917-1668
Practice Address - Fax:941-917-4232
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL26122422085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL305410100Medicaid
FLU0508Medicare ID - Type Unspecified
P86389Medicare UPIN