Provider Demographics
NPI:1164675450
Name:JOHNSON NSOFOR, EDITH NNENNA
Entity Type:Individual
Prefix:
First Name:EDITH
Middle Name:NNENNA
Last Name:JOHNSON NSOFOR
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 1:17515 109TH AVE
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11433-2601
Mailing Address - Country:US
Mailing Address - Phone:347-415-3748
Mailing Address - Fax:
Practice Address - Street 1:17515 109TH AVE
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11433-2601
Practice Address - Country:US
Practice Address - Phone:347-415-3748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-30
Last Update Date:2008-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY286808-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse