Provider Demographics
NPI:1770564189
Name:JOHNSON, PAMELA VANESSA (ARNP)
Entity type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:VANESSA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 N DEERFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33441-2028
Mailing Address - Country:US
Mailing Address - Phone:561-900-6737
Mailing Address - Fax:954-422-1726
Practice Address - Street 1:331 N DEERFIELD AVE
Practice Address - Street 2:
Practice Address - City:DEERFIELD BEACH
Practice Address - State:FL
Practice Address - Zip Code:33441-2028
Practice Address - Country:US
Practice Address - Phone:561-900-6737
Practice Address - Fax:954-422-1726
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-11
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2155102363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY127FOtherBCBSFL
FL308064100Medicaid
FLQ58087Medicare UPIN
FL308064100Medicaid