Provider Demographics
NPI:1972508422
Name:JOHNSON, DONALD L (ARNP)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3215 WINTER LAKE RD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-9709
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3215 WINTER LAKE RD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-9709
Practice Address - Country:US
Practice Address - Phone:863-419-3322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1323862363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL306325900Medicaid
FLU2899WMedicare UPIN
FLQ20659Medicare PIN