Provider Demographics
NPI:1144525478
Name:JOHNSON, MICHELE (ARNP)
Entity type:Individual
Prefix:MRS
First Name:MICHELE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:MICHELE
Other - Middle Name:
Other - Last Name:BRACEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2901 58TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST. PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33714-1326
Mailing Address - Country:US
Mailing Address - Phone:727-822-4300
Mailing Address - Fax:727-456-1399
Practice Address - Street 1:601 5TH ST S
Practice Address - Street 2:SUITE #605
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4804
Practice Address - Country:US
Practice Address - Phone:727-822-4300
Practice Address - Fax:727-456-1399
Is Sole Proprietor?:No
Enumeration Date:2011-01-18
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1183002363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003411800Medicaid