Provider Demographics
NPI:1043092299
Name:JOHNSON, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3817 BELLE VIS
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46619-2944
Mailing Address - Country:US
Mailing Address - Phone:574-217-2770
Mailing Address - Fax:
Practice Address - Street 1:3817 BELLE VIS
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46619-2944
Practice Address - Country:US
Practice Address - Phone:574-217-2770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-20
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle
No344600000XTransportation ServicesTaxi
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No347B00000XTransportation ServicesBus