Provider Demographics
NPI:1598055642
Name:JOHNSON, SHARITA NICOLLE (MD)
Entity Type:Individual
Prefix:DR
First Name:SHARITA
Middle Name:NICOLLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
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 763
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26507-0763
Mailing Address - Country:US
Mailing Address - Phone:800-541-4009
Mailing Address - Fax:
Practice Address - Street 1:117 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26847-9566
Practice Address - Country:US
Practice Address - Phone:800-541-4009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-11
Last Update Date:2017-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101256435207P00000X
WV27400207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine