Provider Demographics
NPI:1275852436
Name:JOHNSON, REATHA (RN)
Entity Type:Individual
Prefix:
First Name:REATHA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 RICE BENT WAY
Mailing Address - Street 2:UNIT 8
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229-6849
Mailing Address - Country:US
Mailing Address - Phone:803-865-8113
Mailing Address - Fax:803-865-8173
Practice Address - Street 1:101 RICE BENT WAY
Practice Address - Street 2:UNIT 8
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29229-6849
Practice Address - Country:US
Practice Address - Phone:803-865-8113
Practice Address - Fax:803-865-8173
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-26
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC38623163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse