Provider Demographics
NPI:1770773749
Name:HABERSHAM-JOHNSON, CONNIE D (LPN)
Entity type:Individual
Prefix:MISS
First Name:CONNIE
Middle Name:D
Last Name:HABERSHAM-JOHNSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:CONNIE
Other - Middle Name:D
Other - Last Name:HABERSHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:261 CONNECTICUT DR
Mailing Address - Street 2:STE 5
Mailing Address - City:BURLINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08016-0151
Mailing Address - Country:US
Mailing Address - Phone:856-785-8109
Mailing Address - Fax:
Practice Address - Street 1:2250 HICKORY RD
Practice Address - Street 2:SUITE 216
Practice Address - City:PLYMOUTH
Practice Address - State:PA
Practice Address - Zip Code:19462
Practice Address - Country:US
Practice Address - Phone:800-950-6066
Practice Address - Fax:609-387-7540
Is Sole Proprietor?:No
Enumeration Date:2007-07-26
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NP03799200164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse