Provider Demographics
NPI:1568073724
Name:JOHNSTON, CONNIE S
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:S
Last Name:JOHNSTON
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 1:1029 WILD DOG PASS # 10
Mailing Address - Street 2:
Mailing Address - City:DELRAY
Mailing Address - State:WV
Mailing Address - Zip Code:26714-4629
Mailing Address - Country:US
Mailing Address - Phone:304-851-7497
Mailing Address - Fax:
Practice Address - Street 1:1029 WILD DOG PASS
Practice Address - Street 2:
Practice Address - City:DELRAY
Practice Address - State:WV
Practice Address - Zip Code:26714-4629
Practice Address - Country:US
Practice Address - Phone:304-851-7497
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-12
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker