Provider Demographics
NPI:1205361326
Name:JOHNSON, TELYCIA MARIE (DO)
Entity type:Individual
Prefix:DR
First Name:TELYCIA
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2760 GODWIN BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-8501
Mailing Address - Country:US
Mailing Address - Phone:757-983-8650
Mailing Address - Fax:
Practice Address - Street 1:2760 GODWIN BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-8501
Practice Address - Country:US
Practice Address - Phone:757-983-8650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-26
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102206536207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine