Provider Demographics
NPI:1396585378
Name:JOHNSON, CHARLOTTE MATTEA
Entity type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:MATTEA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4951 NW 18TH ST
Mailing Address - Street 2:
Mailing Address - City:LAUDERHILL
Mailing Address - State:FL
Mailing Address - Zip Code:33313-4117
Mailing Address - Country:US
Mailing Address - Phone:754-213-1031
Mailing Address - Fax:
Practice Address - Street 1:1314 E LAS OLAS BLVD
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33301-2334
Practice Address - Country:US
Practice Address - Phone:754-213-1031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-28
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier