Provider Demographics
NPI:1124832688
Name:JOHNSON TAYLOR, MITZIE (FNP-BC)
Entity type:Individual
Prefix:
First Name:MITZIE
Middle Name:
Last Name:JOHNSON TAYLOR
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11962 SW PARADISE RIVER RD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34987-7762
Mailing Address - Country:US
Mailing Address - Phone:754-224-9865
Mailing Address - Fax:
Practice Address - Street 1:3300 S UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33328-2004
Practice Address - Country:US
Practice Address - Phone:754-224-9865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-05
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11037479363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily