Provider Demographics
NPI:1023795622
Name:CAMILLE, JOHNNY
Entity type:Individual
Prefix:
First Name:JOHNNY
Middle Name:
Last Name:CAMILLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2450 BATES AVE SW
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-2448
Mailing Address - Country:US
Mailing Address - Phone:863-877-6041
Mailing Address - Fax:
Practice Address - Street 1:2450 BATES AVE SW
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-2448
Practice Address - Country:US
Practice Address - Phone:863-877-6041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-05
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL238688374U00000X, 251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No374U00000XNursing Service Related ProvidersHome Health Aide