Provider Demographics
NPI:1730179698
Name:JOHNSON, JON DAVID (ARNP)
Entity type:Individual
Prefix:MR
First Name:JON
Middle Name:DAVID
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12049 SW 76TH TER
Mailing Address - Street 2:
Mailing Address - City:LAKE BUTLER
Mailing Address - State:FL
Mailing Address - Zip Code:32054-7724
Mailing Address - Country:US
Mailing Address - Phone:386-496-4428
Mailing Address - Fax:
Practice Address - Street 1:495 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LAKE BUTLER
Practice Address - State:FL
Practice Address - Zip Code:32054-1731
Practice Address - Country:US
Practice Address - Phone:386-496-3211
Practice Address - Fax:386-496-1599
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2013-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9197452363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL306277500Medicaid
FL660083200Medicaid
FL306277500Medicaid
FL660083200Medicaid