Provider Demographics
NPI:1790213627
Name:JOHNSON, TONYA ALICIA
Entity Type:Individual
Prefix:
First Name:TONYA
Middle Name:ALICIA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15260 NW 29TH TER
Mailing Address - Street 2:
Mailing Address - City:REDDICK
Mailing Address - State:FL
Mailing Address - Zip Code:32686-3332
Mailing Address - Country:US
Mailing Address - Phone:352-857-4223
Mailing Address - Fax:
Practice Address - Street 1:15260 NW 29TH TER
Practice Address - Street 2:
Practice Address - City:REDDICK
Practice Address - State:FL
Practice Address - Zip Code:32686-3332
Practice Address - Country:US
Practice Address - Phone:352-857-4223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home