Provider Demographics
NPI:1700184892
Name:GARCIA, JOHANNIE
Entity Type:Individual
Prefix:
First Name:JOHANNIE
Middle Name:
Last Name:GARCIA
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 1:367 GIANNA WAY
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086
Mailing Address - Country:US
Mailing Address - Phone:904-826-7886
Mailing Address - Fax:
Practice Address - Street 1:910 S. WINTERHAWK DR. # 107
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-3858
Practice Address - Country:US
Practice Address - Phone:904-826-7886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-14
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12653174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003576500Medicaid