Provider Demographics
NPI:1306005087
Name:JOHNSON, SUNDRA RENEE
Entity Type:Individual
Prefix:MS
First Name:SUNDRA
Middle Name:RENEE
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 1:1414 26TH ST
Mailing Address - Street 2:1414 26TH STREET
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35401-6642
Mailing Address - Country:US
Mailing Address - Phone:205-752-6081
Mailing Address - Fax:
Practice Address - Street 1:1414 26TH ST
Practice Address - Street 2:1414 26TH STREET
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35401-6642
Practice Address - Country:US
Practice Address - Phone:205-752-6081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-06
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL102375171000000X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider
No172V00000XOther Service ProvidersCommunity Health Worker