Provider Demographics
NPI:1790129567
Name:JOHNSON, SHERRY TERESA
Entity Type:Individual
Prefix:MISS
First Name:SHERRY
Middle Name:TERESA
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 1:4045 INDIAN HEAD HWY
Mailing Address - Street 2:APT 5
Mailing Address - City:INDIAN HEAD
Mailing Address - State:MD
Mailing Address - Zip Code:20640
Mailing Address - Country:US
Mailing Address - Phone:301-743-3676
Mailing Address - Fax:
Practice Address - Street 1:4045 INDIAN HEAD HWY
Practice Address - Street 2:APT 5
Practice Address - City:INDIAN HEAD
Practice Address - State:MD
Practice Address - Zip Code:20640-1741
Practice Address - Country:US
Practice Address - Phone:301-743-3676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-24
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDL15123680171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor