Provider Demographics
NPI:1356122634
Name:JOHNSON, DE'LA (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:DE'LA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1268
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32170-1268
Mailing Address - Country:US
Mailing Address - Phone:386-259-8803
Mailing Address - Fax:386-213-9981
Practice Address - Street 1:PO BOX 1268
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32170-1268
Practice Address - Country:US
Practice Address - Phone:386-259-8803
Practice Address - Fax:386-213-9981
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-11
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11029119208VP0000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAPRN1029119Medicaid