Provider Demographics
NPI:1316725658
Name:JOHNSON, EARNEST
Entity type:Individual
Prefix:
First Name:EARNEST
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11925 BRIGHTON KNOLL LOOP
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33579-2201
Mailing Address - Country:US
Mailing Address - Phone:813-668-4420
Mailing Address - Fax:
Practice Address - Street 1:11925 BRIGHTON KNOLL LOOP
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33579-2201
Practice Address - Country:US
Practice Address - Phone:813-668-4420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-18
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9406449163W00000X
FLJ525553845310172A00000X
FLJ525218734150172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
No163W00000XNursing Service ProvidersRegistered Nurse