Provider Demographics
NPI:1164200176
Name:JOHNSON, DEBRIKA
Entity Type:Individual
Prefix:
First Name:DEBRIKA
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 1:5784 HIGHWAY 90
Mailing Address - Street 2:
Mailing Address - City:THEODORE
Mailing Address - State:AL
Mailing Address - Zip Code:36582-1689
Mailing Address - Country:US
Mailing Address - Phone:251-873-0023
Mailing Address - Fax:
Practice Address - Street 1:5784 HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:THEODORE
Practice Address - State:AL
Practice Address - Zip Code:36582-1689
Practice Address - Country:US
Practice Address - Phone:251-873-0023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-20
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-172279163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse