Provider Demographics
NPI:1659845311
Name:JOHNSON, POLLY ANNA
Entity type:Individual
Prefix:MRS
First Name:POLLY
Middle Name:ANNA
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 1:11470 88TH AVE
Mailing Address - Street 2:
Mailing Address - City:SEMINOLE
Mailing Address - State:FL
Mailing Address - Zip Code:33772-3602
Mailing Address - Country:US
Mailing Address - Phone:727-953-0261
Mailing Address - Fax:727-623-0676
Practice Address - Street 1:11470 88TH AVE
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:FL
Practice Address - Zip Code:33772-3602
Practice Address - Country:US
Practice Address - Phone:727-953-0261
Practice Address - Fax:727-623-0676
Is Sole Proprietor?:No
Enumeration Date:2019-01-16
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLJ525-661-528-02255A2300X
3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer