Provider Demographics
NPI:1235862095
Name:JOHNSON, BREAH SHANICE
Entity Type:Individual
Prefix:
First Name:BREAH
Middle Name:SHANICE
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 1:90 HAMMONDS LN APT 245
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MD
Mailing Address - Zip Code:21225-3679
Mailing Address - Country:US
Mailing Address - Phone:678-939-5446
Mailing Address - Fax:
Practice Address - Street 1:301 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-5803
Practice Address - Country:US
Practice Address - Phone:410-787-4702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-07
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program