Provider Demographics
NPI:1316541139
Name:JOHNSON, JOAN MICHELLE
Entity Type:Individual
Prefix:MRS
First Name:JOAN
Middle Name:MICHELLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JOAN
Other - Middle Name:MICHELLE
Other - Last Name:STEWART
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:45 CASTLE HAVEN RD
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-6032
Mailing Address - Country:US
Mailing Address - Phone:757-329-6773
Mailing Address - Fax:
Practice Address - Street 1:13000 WARWICK BLVD
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602-8340
Practice Address - Country:US
Practice Address - Phone:757-269-0136
Practice Address - Fax:757-269-0183
Is Sole Proprietor?:No
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202011969183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist