Provider Demographics
NPI:1003170945
Name:JOHNSON, JAIME LYNN
Entity Type:Individual
Prefix:MRS
First Name:JAIME
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:JAIME
Other - Middle Name:LYNN
Other - Last Name:TAVERA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2510 WESTCHESTER AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-3512
Mailing Address - Country:US
Mailing Address - Phone:718-597-5558
Mailing Address - Fax:
Practice Address - Street 1:2510 WESTCHESTER AVE STE 102
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-3512
Practice Address - Country:US
Practice Address - Phone:718-597-5558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-26
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY624934051174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist