Provider Demographics
NPI:1457995490
Name:JOHANSSON, ASHLEY LYN (PA-C)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:LYN
Last Name:JOHANSSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:LYN
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2073 SYKES CREEK DR
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-3066
Mailing Address - Country:US
Mailing Address - Phone:321-604-8718
Mailing Address - Fax:
Practice Address - Street 1:830 EXECUTIVE LN STE 150
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-3595
Practice Address - Country:US
Practice Address - Phone:321-877-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-02
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9112715363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant