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
State | License ID | Taxonomies |
---|---|---|
PA | 881469 | 251E00000X |
251S00000X, 343900000X, 374U00000X, 376K00000X, 251E00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 251E00000X | Agencies | Home Health | |
No | 251S00000X | Agencies | Community/Behavioral Health | |
No | 343900000X | Transportation Services | Non-emergency Medical Transport (VAN) | |
No | 374U00000X | Nursing Service Related Providers | Home Health Aide | |
No | 376K00000X | Nursing Service Related Providers | Nurse's Aide |