Provider Demographics
NPI:1184345605
Name:JOHNSON, OCTAVIA SAMTESHIA (CNA)
Entity type:Individual
Prefix:
First Name:OCTAVIA
Middle Name:SAMTESHIA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:919 S 25TH ST APT 2-102
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34947-4602
Mailing Address - Country:US
Mailing Address - Phone:772-801-7771
Mailing Address - Fax:
Practice Address - Street 1:919 S 25TH ST APT 2-102
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34947-4602
Practice Address - Country:US
Practice Address - Phone:772-801-7771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-05
Last Update Date:2023-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No372600000XNursing Service Related ProvidersAdult Companion
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider