Provider Demographics
NPI:1821636812
Name:JOHNSON, CYNTHIA MALIA
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:MALIA
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 1:8300 BOONE BLVD STE 500
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-2681
Mailing Address - Country:US
Mailing Address - Phone:703-714-9524
Mailing Address - Fax:
Practice Address - Street 1:8300 BOONE BLVD STE 500
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182-2681
Practice Address - Country:US
Practice Address - Phone:703-714-9524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-20
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAA60819460103TH0100X
WVG1629923747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service