Provider Demographics
NPI:1891348256
Name:JOHNSON, COURTANEY RAE (NP-C)
Entity Type:Individual
Prefix:
First Name:COURTANEY
Middle Name:RAE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 S OCEAN DR STE 209
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33019-2915
Mailing Address - Country:US
Mailing Address - Phone:305-466-9988
Mailing Address - Fax:305-466-9989
Practice Address - Street 1:289 S CULVER ST
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046
Practice Address - Country:US
Practice Address - Phone:305-466-9988
Practice Address - Fax:305-466-9989
Is Sole Proprietor?:No
Enumeration Date:2019-07-24
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23050363LF0000X
GARN164335363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily