Provider Demographics
NPI:1679924716
Name:JOHNSON, STEPHEN WESLEY (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:WESLEY
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2605 THOMAS DR STE 120
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32408-6254
Mailing Address - Country:US
Mailing Address - Phone:850-215-7095
Mailing Address - Fax:850-215-7096
Practice Address - Street 1:2605 THOMAS DR STE 120
Practice Address - Street 2:
Practice Address - City:PANAMA CITY BEACH
Practice Address - State:FL
Practice Address - Zip Code:32408-6254
Practice Address - Country:US
Practice Address - Phone:850-215-7095
Practice Address - Fax:850-215-7096
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-30
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9307095363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAPRN9307095OtherFLORIDA APRN LICENSE
FL118056200Medicaid