Provider Demographics
NPI:1104214493
Name:JOHNSON, MYRIA (LPN)
Entity Type:Individual
Prefix:
First Name:MYRIA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 JOHNES ST
Mailing Address - Street 2:APT 210J
Mailing Address - City:NEWBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12550-5615
Mailing Address - Country:US
Mailing Address - Phone:917-209-0699
Mailing Address - Fax:
Practice Address - Street 1:44 JOHNES ST
Practice Address - Street 2:APT 210J
Practice Address - City:NEWBURGH
Practice Address - State:NY
Practice Address - Zip Code:12550-5615
Practice Address - Country:US
Practice Address - Phone:917-209-0699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-08
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY299004-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse