Basic Information
| Provider Information | |||||||||
| NPI: | 1700870631 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | VICKY | ||||||||
| MiddleName: | C | ||||||||
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| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6015 POINTE WEST BLVD | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342095532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417921404 | ||||||||
| FaxNumber: | 9417610712 | ||||||||
| Practice Location | |||||||||
| Address1: | 6015 POINTE WEST BLVD | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342095532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417921404 | ||||||||
| FaxNumber: | 9417610712 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2005 | ||||||||
| LastUpdateDate: | 09/29/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 932572 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | G9011 | 01 | BCBS | OTHER |