Provider Demographics
NPI:1306032081
Name:NDERI JOHNSON, JANE
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:
Last Name:NDERI 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 1:113 PETERS ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13208-2729
Mailing Address - Country:US
Mailing Address - Phone:315-479-5588
Mailing Address - Fax:
Practice Address - Street 1:113 PETERS ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13208-2729
Practice Address - Country:US
Practice Address - Phone:315-479-5588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-17
Last Update Date:2007-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY281547164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse