Provider Demographics
NPI:1003250101
Name:JOHNSON-MASON, TYREASEA ANICHA (NP)
Entity Type:Individual
Prefix:
First Name:TYREASEA
Middle Name:ANICHA
Last Name:JOHNSON-MASON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 HIGHLAND AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:HADDON TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:08108-2634
Mailing Address - Country:US
Mailing Address - Phone:609-350-4792
Mailing Address - Fax:856-823-1922
Practice Address - Street 1:215 HIGHLAND AVE STE 100
Practice Address - Street 2:
Practice Address - City:HADDON TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:08108-2634
Practice Address - Country:US
Practice Address - Phone:609-350-4792
Practice Address - Fax:856-823-1922
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-19
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP012833363LP0808X
NJ26NJ00429100363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0379077Medicaid
NJ1003250101OtherNPI
NJ1003250101OtherNPI