Provider Demographics
NPI:1407503378
Name:JOHNSON, DWAYNE E
Entity Type:Individual
Prefix:
First Name:DWAYNE
Middle Name:E
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CHALFORD LN
Mailing Address - Street 2:
Mailing Address - City:WILLINGBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08046-3401
Mailing Address - Country:US
Mailing Address - Phone:609-850-0055
Mailing Address - Fax:866-534-9942
Practice Address - Street 1:JFK SENIOR CENTER
Practice Address - Street 2:429 JFK WAY
Practice Address - City:WILLINGBORO
Practice Address - State:NJ
Practice Address - Zip Code:08046
Practice Address - Country:US
Practice Address - Phone:609-850-0055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-09
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date: