Provider Demographics
NPI:1578185369
Name:JOHNSON, MARION
Entity Type:Individual
Prefix:
First Name:MARION
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 1:9633 CLOCKTOWER LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21046-1877
Mailing Address - Country:US
Mailing Address - Phone:240-535-6111
Mailing Address - Fax:
Practice Address - Street 1:9633 CLOCKTOWER LN
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21046-1877
Practice Address - Country:US
Practice Address - Phone:240-535-6111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-14
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR187659163WP0808X
DC1040399163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health