Provider Demographics
NPI:1851883706
Name:JOHNSON, TARA DEMETRIA
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:DEMETRIA
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 1:304 HANFORD RD SW
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32908-1200
Mailing Address - Country:US
Mailing Address - Phone:321-480-4052
Mailing Address - Fax:
Practice Address - Street 1:226 ABALONE RD NW
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-2964
Practice Address - Country:US
Practice Address - Phone:321-480-4052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-05
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLALF13181310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLFLMedicaid