Provider Demographics
NPI:1659726750
Name:SUDINE JOHNSON
Entity Type:Organization
Organization Name:SUDINE JOHNSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CNA
Authorized Official - Prefix:
Authorized Official - First Name:SUDINE
Authorized Official - Middle Name:S
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-663-8247
Mailing Address - Street 1:1230 W POINTE VILLAS BLVD BLDG APT 203
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-6099
Mailing Address - Country:US
Mailing Address - Phone:321-663-8247
Mailing Address - Fax:
Practice Address - Street 1:1230 W POINTE VILLAS BLVD BLDG APT 203
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-6099
Practice Address - Country:US
Practice Address - Phone:321-663-8247
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-27
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL322032302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization