Provider Demographics
NPI:1629626700
Name:JOHNSON, MARCIA MICHELLE
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:MICHELLE
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 1:10407 DURNESS DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63137-3758
Mailing Address - Country:US
Mailing Address - Phone:314-667-8149
Mailing Address - Fax:
Practice Address - Street 1:737 DERBY WAY DR
Practice Address - Street 2:
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-4711
Practice Address - Country:US
Practice Address - Phone:402-969-0094
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-31
Last Update Date:2019-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOLC001601639OtherHOME CARE