Provider Demographics
NPI:1255923090
Name:JOHNSOM, EVELYN BERNICE
Entity type:Individual
Prefix:
First Name:EVELYN
Middle Name:BERNICE
Last Name:JOHNSOM
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 1:80 FRANK WILKERSON DR
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27801-7876
Mailing Address - Country:US
Mailing Address - Phone:252-813-5062
Mailing Address - Fax:
Practice Address - Street 1:80 FRANK WILKERSON DR
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27801-7876
Practice Address - Country:US
Practice Address - Phone:252-813-5062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-03
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant