Provider Demographics
NPI:1093381030
Name:JOHNSON, MARQUETTA (LICENSED PRACTICAL N)
Entity Type:Individual
Prefix:
First Name:MARQUETTA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LICENSED PRACTICAL N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 E CENTER ST APT 343
Mailing Address - Street 2:
Mailing Address - City:MEBANE
Mailing Address - State:NC
Mailing Address - Zip Code:27302-2561
Mailing Address - Country:US
Mailing Address - Phone:314-437-3008
Mailing Address - Fax:
Practice Address - Street 1:201 E CENTER ST APT 343
Practice Address - Street 2:
Practice Address - City:MEBANE
Practice Address - State:NC
Practice Address - Zip Code:27302-2561
Practice Address - Country:US
Practice Address - Phone:314-437-3008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-01
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2001008578164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse