Basic Information
| Provider Information | |||||||||
| NPI: | 1811269962 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | VON-NICA | ||||||||
| MiddleName: | W. | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APRN, CNM | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WALKER | ||||||||
| OtherFirstName: | VON-NICA | ||||||||
| OtherMiddleName: | R | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | APRN, CNM | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 25317 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336225317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132860033 | ||||||||
| FaxNumber: | 8132821806 | ||||||||
| Practice Location | |||||||||
| Address1: | 1680 EAGLE HARBOR PKWY STE A | ||||||||
| Address2: | |||||||||
| City: | ORANGE PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320034821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042649555 | ||||||||
| FaxNumber: | 9042157960 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2012 | ||||||||
| LastUpdateDate: | 07/24/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | ARNP9233376 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 367A00000X | APRN9233376 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 004548000 | 05 | FL | MEDICAID |