Provider Demographics
NPI:1821678889
Name:JOHNSON, REBECCA KEITH
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:KEITH
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:ASHLEY
Other - Last Name:KEITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:914 ORAPAX ST APT G
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23507-1357
Mailing Address - Country:US
Mailing Address - Phone:540-313-1096
Mailing Address - Fax:
Practice Address - Street 1:600 GRESHAM DR STE 304
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1904
Practice Address - Country:US
Practice Address - Phone:757-388-3397
Practice Address - Fax:757-388-2885
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-13
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program