Provider Demographics
NPI:1922361161
Name:JOHNSON, MARIAN DIANE
Entity Type:Individual
Prefix:
First Name:MARIAN
Middle Name:DIANE
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 1:8449 168TH ST APT 4W
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-2005
Mailing Address - Country:US
Mailing Address - Phone:718-657-6238
Mailing Address - Fax:
Practice Address - Street 1:8449 168TH ST APT 4W
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-2005
Practice Address - Country:US
Practice Address - Phone:718-657-6238
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-22
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist