Mary Johnson, ARNP

Primary specialty

Family Nurse PractitionerTaxonomy code 363LF0000X

License

1466102 Issued in FL

Practice address

7575 Osceola Polk Line Rd
Davenport, FL 33896-9112

Phone

(321) 677-0531

Fax

(321) 677-0537

NPI assigned

Apr 14, 2006

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Opted out of Medicare

Yes, effective Oct 1, 2017 through Oct 1, 2027

Medicare enrollment (NPD)

Enrolled

Credentials

Nurse Practitioner

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Lifestream Behavioral Center Inc

  • Primary Care Clinic/Center
  • Leesburg, FL
  • NPI 1659613776
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1144972800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1314835200000",
    "number": "1750345898",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "12 SOUTH BLVD E",
            "city": "DAVENPORT",
            "state": "FL",
            "postal_code": "338377542",
            "telephone_number": "321-677-0531",
            "fax_number": "321-677-0537"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "7575 OSCEOLA POLK LINE RD",
            "city": "DAVENPORT",
            "state": "FL",
            "postal_code": "338969112",
            "telephone_number": "321-677-0531",
            "fax_number": "321-677-0537"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JOHNSON",
        "first_name": "MARY",
        "credential": "ARNP",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-04-14",
        "last_updated": "2011-09-01",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "FL",
            "license": "1466102",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "304941800",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Sussy Jimenez
• Alyssa Johnson, SLPA
• Amanda Johnson, CRNA
• Denyelle K Johnson, RBT
• Emily Johnson
• Runako Ayana Johnson, PTA
• Eddy Jonas, SA-C
• Karen Arlet Jones
• Margaret Mae Jorge, APRN
• Lance Joseph, DDS

• Family Nurse Practitioner in Davenport, FL
• Providers in Davenport, FL by specialty
• Family Nurse Practitioner in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 1, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring; Opt Out Affidavits.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.