Provider Demographics
NPI:1821330275
Name:HURSON, JOHANNE
Entity Type:Individual
Prefix:
First Name:JOHANNE
Middle Name:
Last Name:HURSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JOHANNE
Other - Middle Name:
Other - Last Name:WALLECK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3156 GROVEHURST PL
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22310-2350
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6355 WALKER LN
Practice Address - Street 2:SUITE 204
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22310-3245
Practice Address - Country:US
Practice Address - Phone:703-810-5211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-25
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA23052078242251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic