Provider Demographics
NPI:1548734189
Name:JOHNSON, HEATHER A (DOM)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21758 US HIGHWAY 331 N
Mailing Address - Street 2:
Mailing Address - City:LAUREL HILL
Mailing Address - State:FL
Mailing Address - Zip Code:32567-3747
Mailing Address - Country:US
Mailing Address - Phone:850-603-9466
Mailing Address - Fax:850-834-3110
Practice Address - Street 1:22395 US HIGHWAY 331 N
Practice Address - Street 2:
Practice Address - City:LAUREL HILL
Practice Address - State:FL
Practice Address - Zip Code:32567-3309
Practice Address - Country:US
Practice Address - Phone:850-603-9000
Practice Address - Fax:888-347-5228
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-16
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP2798171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty