Provider Demographics
NPI:1518772516
Name:CLEMONS, JOHNNETTA LATRICE (COSMETOLOGIST INSTUR)
Entity type:Individual
Prefix:
First Name:JOHNNETTA
Middle Name:LATRICE
Last Name:CLEMONS
Suffix:
Gender:
Credentials:COSMETOLOGIST INSTUR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10209 E COLONIAL DR STE 160
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32817-4337
Mailing Address - Country:US
Mailing Address - Phone:407-413-5330
Mailing Address - Fax:
Practice Address - Street 1:10209 E COLONIAL DR STE 160
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32817-4337
Practice Address - Country:US
Practice Address - Phone:407-413-5330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-08
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCL1250980225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner