Provider Demographics
NPI:1043331440
Name:JOHNSON, WANDA SUE (RMF/CMF)
Entity Type:Individual
Prefix:MRS
First Name:WANDA
Middle Name:SUE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RMF/CMF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4228 GARRETT RD
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-3430
Mailing Address - Country:US
Mailing Address - Phone:919-489-7408
Mailing Address - Fax:919-490-5909
Practice Address - Street 1:4228 GARRETT RD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-3430
Practice Address - Country:US
Practice Address - Phone:919-489-7408
Practice Address - Fax:919-490-5909
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC335E00000X
174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7795110Medicaid