Provider Demographics
NPI:1750971172
Name:AUSTIN, MARY JOHNSON
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JOHNSON
Last Name:AUSTIN
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 1:1230 E CLEMMONSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27107-4206
Mailing Address - Country:US
Mailing Address - Phone:336-546-2503
Mailing Address - Fax:
Practice Address - Street 1:1230 E CLEMMONSVILLE RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27107-4206
Practice Address - Country:US
Practice Address - Phone:336-546-2503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-20
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide