Provider Demographics
NPI:1801517651
Name:JOHNSON, WILLIE (GM)
Entity type:Individual
Prefix:
First Name:WILLIE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:GM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23781 HWY 27 # 226
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33859-7802
Mailing Address - Country:US
Mailing Address - Phone:863-269-8897
Mailing Address - Fax:
Practice Address - Street 1:108 JULIE LN
Practice Address - Street 2:
Practice Address - City:AUBURNDALE
Practice Address - State:FL
Practice Address - Zip Code:33823-2335
Practice Address - Country:US
Practice Address - Phone:863-269-8897
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-09
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL207693332BP3500X
FL207683332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition