Provider Demographics
NPI:1760703664
Name:JOHNSON MERCURIO, CARRIE
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:JOHNSON MERCURIO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7878 CHASE RD
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:NY
Mailing Address - Zip Code:14485-9604
Mailing Address - Country:US
Mailing Address - Phone:585-314-1915
Mailing Address - Fax:
Practice Address - Street 1:7878 CHASE RD
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:NY
Practice Address - Zip Code:14485-9604
Practice Address - Country:US
Practice Address - Phone:585-314-1915
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-15
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY290074-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse