Provider Demographics
NPI:1740833532
Name:JOHNSON, ANIYA D
Entity type:Individual
Prefix:
First Name:ANIYA
Middle Name:D
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 1:191 N LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12206-2726
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:191 N LAKE AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12206-2726
Practice Address - Country:US
Practice Address - Phone:518-833-3644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-20
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No251J00000XAgenciesNursing Care
No3140N1450XNursing & Custodial Care FacilitiesSkilled Nursing FacilityNursing Care, Pediatric
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
No376G00000XNursing Service Related ProvidersNursing Home Administrator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY871240966OtherID