Provider Demographics
NPI:1851122956
Name:JOHNSON, SAMANTHIA (LPN)
Entity type:Individual
Prefix:
First Name:SAMANTHIA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4650 LIPSCOMB ST NE STE 14
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-2997
Mailing Address - Country:US
Mailing Address - Phone:321-527-4019
Mailing Address - Fax:
Practice Address - Street 1:4650 LIPSCOMB ST NE STE 14
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-2997
Practice Address - Country:US
Practice Address - Phone:321-527-4019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-09
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN5228272164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse