Provider Demographics
NPI:1619196482
Name:JOHNSON, MARLENA RAE (SA)
Entity Type:Individual
Prefix:MS
First Name:MARLENA
Middle Name:RAE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:SA
Other - Prefix:MS
Other - First Name:MARLENA
Other - Middle Name:RAE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:SA
Mailing Address - Street 1:2765 PIERCE ST
Mailing Address - Street 2:
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80214-8050
Mailing Address - Country:US
Mailing Address - Phone:303-232-9297
Mailing Address - Fax:303-232-9297
Practice Address - Street 1:2765 PIERCE ST
Practice Address - Street 2:
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80214-8050
Practice Address - Country:US
Practice Address - Phone:303-232-9297
Practice Address - Fax:303-232-9297
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO97142246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist