Provider Demographics
NPI:1194001347
Name:JOHNSON, CORA THOMAS
Entity Type:Individual
Prefix:MRS
First Name:CORA
Middle Name:THOMAS
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:CORA
Other - Middle Name:LAVETTE
Other - Last Name:WARDRETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:703 NEWPORT NEWS AVE
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23669-3932
Mailing Address - Country:US
Mailing Address - Phone:757-256-4902
Mailing Address - Fax:757-325-2162
Practice Address - Street 1:703 NEWPORT NEWS AVE
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23669-3932
Practice Address - Country:US
Practice Address - Phone:757-256-4902
Practice Address - Fax:757-325-2162
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-01
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant