Provider Demographics
NPI:1154672772
Name:JOHNSON, SANDRA
Entity Type:Individual
Prefix:
First Name:SANDRA
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 1:205 STATE ROUTE B STE 8
Mailing Address - Street 2:
Mailing Address - City:SAINT JAMES
Mailing Address - State:MO
Mailing Address - Zip Code:65559-2000
Mailing Address - Country:US
Mailing Address - Phone:573-265-6004
Mailing Address - Fax:
Practice Address - Street 1:205 STATE ROUTE B STE 8
Practice Address - Street 2:
Practice Address - City:SAINT JAMES
Practice Address - State:MO
Practice Address - Zip Code:65559-2000
Practice Address - Country:US
Practice Address - Phone:573-265-6004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-21
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health