Provider Demographics
NPI:1659150456
Name:JOHNSON, DEMETRIA
Entity Type:Individual
Prefix:
First Name:DEMETRIA
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 1:4990 SADLER PL UNIT 2621
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23058-1225
Mailing Address - Country:US
Mailing Address - Phone:516-410-7618
Mailing Address - Fax:
Practice Address - Street 1:11206 ABBOTS CROSS LN
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23059-1106
Practice Address - Country:US
Practice Address - Phone:516-410-7618
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-22
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001264629163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator