Provider Demographics
NPI:1003391731
Name:JOHNSON, EMERY LEROY JR
Entity Type:Individual
Prefix:
First Name:EMERY
Middle Name:LEROY
Last Name:JOHNSON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 FETSKO RD
Mailing Address - Street 2:
Mailing Address - City:WEST MIDDLESEX
Mailing Address - State:PA
Mailing Address - Zip Code:16159-2306
Mailing Address - Country:US
Mailing Address - Phone:724-854-1435
Mailing Address - Fax:
Practice Address - Street 1:3676 N HERMITAGE RD
Practice Address - Street 2:
Practice Address - City:TRANSFER
Practice Address - State:PA
Practice Address - Zip Code:16154-1852
Practice Address - Country:US
Practice Address - Phone:330-726-0700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-28
Last Update Date:2018-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPN274204164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse