Provider Demographics
NPI:1821284605
Name:JOHNSON, TANGIE
Entity Type:Individual
Prefix:
First Name:TANGIE
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 1:904 W LEXINGTON ST
Mailing Address - Street 2:APT. 9
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21223-2544
Mailing Address - Country:US
Mailing Address - Phone:410-728-0949
Mailing Address - Fax:
Practice Address - Street 1:3300 N RIDGE RD
Practice Address - Street 2:SUITE 175
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21043-3383
Practice Address - Country:US
Practice Address - Phone:410-750-3474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-14
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00050949376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide