Provider Demographics
NPI:1013601608
Name:JOHNSTON, GLORIA ALICE (NP)
Entity Type:Individual
Prefix:MS
First Name:GLORIA
Middle Name:ALICE
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2805 TRUMPETER CT
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20601-2614
Mailing Address - Country:US
Mailing Address - Phone:240-353-2516
Mailing Address - Fax:
Practice Address - Street 1:2805 TRUMPETER CT
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20601-2614
Practice Address - Country:US
Practice Address - Phone:240-353-2516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-06
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR219675363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty