Provider Demographics
NPI:1124392410
Name:JOHNSON, CAROLYN AMANDA (LPN)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:AMANDA
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 1:422 E 35TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-5010
Mailing Address - Country:US
Mailing Address - Phone:646-404-1293
Mailing Address - Fax:
Practice Address - Street 1:422 E 35TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-5010
Practice Address - Country:US
Practice Address - Phone:646-404-1293
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-03
Last Update Date:2012-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY307502-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQV76030UMedicaid