Provider Demographics
NPI:1669151577
Name:JOHNSON, ELBA MARINA
Entity type:Individual
Prefix:
First Name:ELBA
Middle Name:MARINA
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 1:13231 SEASIDE HARBOUR DR
Mailing Address - Street 2:
Mailing Address - City:N FT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33903-7118
Mailing Address - Country:US
Mailing Address - Phone:239-565-0004
Mailing Address - Fax:
Practice Address - Street 1:31 BARKLEY CIR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-7628
Practice Address - Country:US
Practice Address - Phone:239-600-7165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN5248559164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse