Provider Demographics
NPI:1669806345
Name:JOHNSON, PEGGY LAVERN
Entity type:Individual
Prefix:
First Name:PEGGY
Middle Name:LAVERN
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 1:4455 CONFEDERATE POINT RD
Mailing Address - Street 2:APARTMENT 10-D
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-5757
Mailing Address - Country:US
Mailing Address - Phone:904-400-8723
Mailing Address - Fax:904-374-5251
Practice Address - Street 1:4455 CONFEDERATE POINT RD
Practice Address - Street 2:APARTMENT 10-D
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-5757
Practice Address - Country:US
Practice Address - Phone:904-400-8723
Practice Address - Fax:904-374-5251
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-29
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL691051396Medicaid