Provider Demographics
NPI:1821186735
Name:JOHNSON, PENNY FLEETWOOD (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:PENNY
Middle Name:FLEETWOOD
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36658 ROBIN HOOD RD
Mailing Address - Street 2:
Mailing Address - City:DELMAR
Mailing Address - State:DE
Mailing Address - Zip Code:19940-2326
Mailing Address - Country:US
Mailing Address - Phone:410-334-2227
Mailing Address - Fax:410-341-3225
Practice Address - Street 1:106 MILFORD ST
Practice Address - Street 2:SUITE 605
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-6953
Practice Address - Country:US
Practice Address - Phone:410-334-2227
Practice Address - Fax:410-341-3225
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR123383363LF0000X
DELG0000336363LF0000X
VA0024171560363LF0000X
PASP013903363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDD542Medicare UPIN
MDP59159Medicare UPIN