Provider Demographics
NPI:1336139278
Name:JOHNSON, DEORA KAYE (DNP, CRNP)
Entity Type:Individual
Prefix:DR
First Name:DEORA
Middle Name:KAYE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DNP, CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7405 QUIXOTE CT
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20720-4354
Mailing Address - Country:US
Mailing Address - Phone:256-323-3886
Mailing Address - Fax:
Practice Address - Street 1:10 NORTH GREENE ST.
Practice Address - Street 2:6D-104
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1524
Practice Address - Country:US
Practice Address - Phone:410-605-7363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-23
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR193679363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health