Provider Demographics
NPI:1396755773
Name:JOHNSON, KATRENA FAYE (SUPPORTED LIVING COA)
Entity type:Individual
Prefix:MRS
First Name:KATRENA
Middle Name:FAYE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:SUPPORTED LIVING COA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 CRUSADERS WAY
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32443-6907
Mailing Address - Country:US
Mailing Address - Phone:850-209-0195
Mailing Address - Fax:850-592-8195
Practice Address - Street 1:4500 CRUSADERS WAY
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:FL
Practice Address - Zip Code:32443-6907
Practice Address - Country:US
Practice Address - Phone:850-209-0195
Practice Address - Fax:850-592-8195
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor