Provider Demographics
NPI:1316957046
Name:JOHNSON, SUSAN R (ARNP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:R
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 6TH AVE S
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-4634
Mailing Address - Country:US
Mailing Address - Phone:727-767-8181
Mailing Address - Fax:727-767-8030
Practice Address - Street 1:501 6TH AVE S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4634
Practice Address - Country:US
Practice Address - Phone:727-767-8181
Practice Address - Fax:727-767-8030
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3072252363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL303458500Medicaid
FLY012GOtherBLUE CROSS BLUE SHIELD
FL500028502Medicare PIN
FLE5125WMedicare PIN
FLY012GOtherBLUE CROSS BLUE SHIELD