Provider Demographics
NPI:1548805187
Name:JOHNSON, TYKEMA OCTAVIA (DNP-APRN)
Entity Type:Individual
Prefix:MRS
First Name:TYKEMA
Middle Name:OCTAVIA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DNP-APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2805 TOWER ROCK ST
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34758-2512
Mailing Address - Country:US
Mailing Address - Phone:321-246-2797
Mailing Address - Fax:
Practice Address - Street 1:400 CELEBRATION PL
Practice Address - Street 2:
Practice Address - City:CELEBRATION
Practice Address - State:FL
Practice Address - Zip Code:34747-4970
Practice Address - Country:US
Practice Address - Phone:407-303-4538
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-07
Last Update Date:2021-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9390446163W00000X
FLAPRN11009495363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse