Provider Demographics
NPI:1972184083
Name:JOHNSON, MARY CALESTINE
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CALESTINE
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 1:255 DELAWARE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14202-2016
Mailing Address - Country:US
Mailing Address - Phone:716-842-0440
Mailing Address - Fax:
Practice Address - Street 1:244 HEMPSTEAD AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215-3404
Practice Address - Country:US
Practice Address - Phone:716-831-7877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-20
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY276119-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse