Provider Demographics
NPI:1568959856
Name:JOHNSON, MOREEN
Entity Type:Individual
Prefix:
First Name:MOREEN
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:CHRISTIAN NURSING REGISTRY
Mailing Address - Street 2:17 BANK AVE
Mailing Address - City:SMITH TOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787
Mailing Address - Country:US
Mailing Address - Phone:631-265-5300
Mailing Address - Fax:
Practice Address - Street 1:CHRISTIAN NURSING REGISTRY
Practice Address - Street 2:17 BANK AVE
Practice Address - City:SMITH TOWN
Practice Address - State:NY
Practice Address - Zip Code:11787
Practice Address - Country:US
Practice Address - Phone:631-265-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-23
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY714762163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical