Provider Demographics
NPI:1629377833
Name:JOHNSON, ERNESTINE VALERIE
Entity Type:Individual
Prefix:MRS
First Name:ERNESTINE
Middle Name:VALERIE
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 1:5220 SETTLERS PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464
Mailing Address - Country:US
Mailing Address - Phone:757-355-4464
Mailing Address - Fax:757-216-7001
Practice Address - Street 1:5220 SETTLERS PARK DRIVE
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464
Practice Address - Country:US
Practice Address - Phone:757-355-3377
Practice Address - Fax:757-216-7001
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-28
Last Update Date:2011-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2011-240443-R332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies