Provider Demographics
NPI:1912300922
Name:JOHNSON, PRINCESS JR
Entity Type:Individual
Prefix:
First Name:PRINCESS
Middle Name:
Last Name:JOHNSON
Suffix:JR
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 1:407 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:GALT
Mailing Address - State:CA
Mailing Address - Zip Code:95632-2048
Mailing Address - Country:US
Mailing Address - Phone:916-821-2391
Mailing Address - Fax:209-912-4141
Practice Address - Street 1:407 MAPLE ST
Practice Address - Street 2:
Practice Address - City:GALT
Practice Address - State:CA
Practice Address - Zip Code:95632-2048
Practice Address - Country:US
Practice Address - Phone:916-821-2391
Practice Address - Fax:209-912-4141
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-04
Last Update Date:2014-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA347005264376G00000X
CA00648092376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376G00000XNursing Service Related ProvidersNursing Home Administrator
No376K00000XNursing Service Related ProvidersNurse's Aide