Provider Demographics
NPI:1811927767
Name:JOHNS, BRENDA WILLIS (LMT)
Entity type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:WILLIS
Last Name:JOHNS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1867 NOLAN RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:FL
Mailing Address - Zip Code:32068-3071
Mailing Address - Country:US
Mailing Address - Phone:904-298-7665
Mailing Address - Fax:904-278-8060
Practice Address - Street 1:2177 KINGSLEY AVE
Practice Address - Street 2:SUITE 11
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-5199
Practice Address - Country:US
Practice Address - Phone:904-298-7665
Practice Address - Fax:904-278-8060
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2009-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA26981225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist