Provider Demographics
NPI:1942633276
Name:JOHNSON, BRENDA LEE (09/28/1965)
Entity Type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:LEE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:09/28/1965
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 SW. SHELBY AVENUE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:FL
Mailing Address - Zip Code:32340-2334
Mailing Address - Country:US
Mailing Address - Phone:850-973-0591
Mailing Address - Fax:
Practice Address - Street 1:308 SW. SHELBY AVENUE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:FL
Practice Address - Zip Code:32340-2334
Practice Address - Country:US
Practice Address - Phone:850-973-0591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-09
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL008047400253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency