Provider Demographics
NPI:1720627110
Name:JOHNSON, REGIST TONYCE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MISS
First Name:REGIST
Middle Name:TONYCE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:REGIS
Other - Middle Name:TONYCE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:4719 HIGHWAY 90
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:FL
Mailing Address - Zip Code:32446-7839
Mailing Address - Country:US
Mailing Address - Phone:850-526-3314
Mailing Address - Fax:
Practice Address - Street 1:4719 HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32446-7839
Practice Address - Country:US
Practice Address - Phone:850-526-3314
Practice Address - Fax:850-526-5022
Is Sole Proprietor?:No
Enumeration Date:2020-01-02
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11005534363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner