Provider Demographics
NPI:1316590136
Name:JOHNSON, GRACE WEDESAMAH BAFFOE
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:WEDESAMAH BAFFOE
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 1:102 BOBRICH DR APT A
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14610-2068
Mailing Address - Country:US
Mailing Address - Phone:917-975-2466
Mailing Address - Fax:
Practice Address - Street 1:102 BOBRICH DR APT A
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14610-2068
Practice Address - Country:US
Practice Address - Phone:917-975-2466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-21
Last Update Date:2019-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY773754163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health