Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | CH4945 | FL |
NPI | 1174523955 |
---|---|
Provider Name | Dr. Alan Lee Johnson |
First Address | Clearwater, FL 33756-5617 |
Second Address | Clearwater, FL 33756-5617 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/07/2005 |
Last Update Date | 15/08/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
T62331 | (02) |