Provider Demographics
NPI:1114560521
Name:JOHNSON, PRICILLA
Entity Type:Individual
Prefix:
First Name:PRICILLA
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 1:5 ROBINHOOD RD
Mailing Address - Street 2:
Mailing Address - City:TYNGSBORO
Mailing Address - State:MA
Mailing Address - Zip Code:01879-1629
Mailing Address - Country:US
Mailing Address - Phone:978-476-9641
Mailing Address - Fax:
Practice Address - Street 1:5 ROBINHOOD RD
Practice Address - Street 2:
Practice Address - City:TYNGSBORO
Practice Address - State:MA
Practice Address - Zip Code:01879-1629
Practice Address - Country:US
Practice Address - Phone:978-476-9641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-18
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2276207163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty