Provider Demographics
NPI:1740227503
Name:JOHNSON, CHRISTINA CERISE (ARNP)
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:CERISE
Last Name:JOHNSON
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 1:12280 LAKE UNDERHILL RD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32825-5009
Mailing Address - Country:US
Mailing Address - Phone:850-682-1002
Mailing Address - Fax:
Practice Address - Street 1:302 E JAMES LEE BLVD
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32539-2827
Practice Address - Country:US
Practice Address - Phone:850-682-1002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9240049363L00000X
FL9240049363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL307414500Medicaid
FLU7073ZMedicare ID - Type Unspecified
FL307414500Medicaid