Provider Demographics
NPI:1558994616
Name:JOHNSON, PORTIA LYNETT
Entity Type:Individual
Prefix:MRS
First Name:PORTIA
Middle Name:LYNETT
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 1:814 ORLANDO CT
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24019-5308
Mailing Address - Country:US
Mailing Address - Phone:540-793-7670
Mailing Address - Fax:
Practice Address - Street 1:814 ORLANDO CT
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24019-5308
Practice Address - Country:US
Practice Address - Phone:540-793-7670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-18
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT23958975172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver