Provider Demographics
NPI:1811269962
Name:JOHNSON, VON-NICA W (APRN, CNM)
Entity type:Individual
Prefix:MRS
First Name:VON-NICA
Middle Name:W
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:APRN, CNM
Other - Prefix:MS
Other - First Name:VON-NICA
Other - Middle Name:R
Other - Last Name:WALKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN, CNM
Mailing Address - Street 1:PO BOX 25317
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33622-5317
Mailing Address - Country:US
Mailing Address - Phone:813-286-0033
Mailing Address - Fax:813-282-1806
Practice Address - Street 1:1680 EAGLE HARBOR PKWY STE A
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32003-4821
Practice Address - Country:US
Practice Address - Phone:904-264-9555
Practice Address - Fax:904-215-7960
Is Sole Proprietor?:No
Enumeration Date:2012-02-06
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9233376363L00000X
FLAPRN9233376367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004548000Medicaid
FLFV875ZMedicare PIN