Provider Demographics
NPI:1780636100
Name:JOHNSON, JILL ANNE (CRNA)
Entity Type:Individual
Prefix:MS
First Name:JILL
Middle Name:ANNE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MS
Other - First Name:JILL
Other - Middle Name:ANNE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:1330 AUTUMN BREEZE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32563-6943
Mailing Address - Country:US
Mailing Address - Phone:850-288-1998
Mailing Address - Fax:
Practice Address - Street 1:1330 AUTUMN BREEZE CIR
Practice Address - Street 2:
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32563-3721
Practice Address - Country:US
Practice Address - Phone:850-288-1998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2012-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9237672367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009935331Medicaid
FLG3901OtherBCBS
FL307317300Medicaid
AL59183488OtherBCBS
AL59183489OtherBCBS
AL59183488OtherBCBS