Provider Demographics
NPI:1932487493
Name:JOHNSON, DANAE ADRIANNE
Entity Type:Individual
Prefix:
First Name:DANAE
Middle Name:ADRIANNE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DANAE
Other - Middle Name:ADRIANNE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:3250 ZEMKE AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33621-5023
Mailing Address - Country:US
Mailing Address - Phone:813-827-9130
Mailing Address - Fax:
Practice Address - Street 1:3250 ZEMKE AVE
Practice Address - Street 2:MACDILL AFB, MEDICAL CLINIC
Practice Address - City:MACDILL AFB
Practice Address - State:FL
Practice Address - Zip Code:33604-5202
Practice Address - Country:US
Practice Address - Phone:813-827-9130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-01
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004769171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider