Provider Demographics
NPI:1073890729
Name:EXANTUS, JOHNSON (LPN)
Entity Type:Individual
Prefix:
First Name:JOHNSON
Middle Name:
Last Name:EXANTUS
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 CROWN ST
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729-6921
Mailing Address - Country:US
Mailing Address - Phone:631-392-0199
Mailing Address - Fax:
Practice Address - Street 1:60 CROWN ST
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:NY
Practice Address - Zip Code:11729-6921
Practice Address - Country:US
Practice Address - Phone:631-392-0199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-09
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY301511164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse