Provider Demographics
NPI:1497412969
Name:JOHNSON, MONICA
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:
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:PO BOX 28542
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19149-0542
Mailing Address - Country:US
Mailing Address - Phone:267-870-7212
Mailing Address - Fax:
Practice Address - Street 1:3472 FRIENDSHIP ST # 1
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19149-1652
Practice Address - Country:US
Practice Address - Phone:267-870-7212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-19
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA881469251E00000X
251S00000X, 343900000X, 374U00000X, 376K00000X, 251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No251S00000XAgenciesCommunity/Behavioral Health
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No374U00000XNursing Service Related ProvidersHome Health Aide
No376K00000XNursing Service Related ProvidersNurse's Aide