Provider Demographics
NPI:1336619436
Name:JOHNSON, JUDY DELOIS
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:DELOIS
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 1:2114 EVERGREEN PL
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23704-5330
Mailing Address - Country:US
Mailing Address - Phone:757-930-9222
Mailing Address - Fax:
Practice Address - Street 1:2114 EVERGREEN PL
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23704-5330
Practice Address - Country:US
Practice Address - Phone:757-930-9222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-30
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1401021473376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide