Provider Demographics
NPI:1013239151
Name:JOHNSON, ADA
Entity Type:Individual
Prefix:
First Name:ADA
Middle Name:
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 1:8045 PEAK RD
Mailing Address - Street 2:
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-9789
Mailing Address - Country:US
Mailing Address - Phone:336-463-5510
Mailing Address - Fax:
Practice Address - Street 1:903 W MAIN ST
Practice Address - Street 2:
Practice Address - City:YADKINVILLE
Practice Address - State:NC
Practice Address - Zip Code:27055-7807
Practice Address - Country:US
Practice Address - Phone:336-463-5510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-16
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2883302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization