Provider Demographics
NPI:1952028946
Name:JOHNSON, PATTIE
Entity Type:Individual
Prefix:MRS
First Name:PATTIE
Middle Name:
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 1:601 EDGEWOOD ST NE APT 309
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20017-3317
Mailing Address - Country:US
Mailing Address - Phone:202-910-9800
Mailing Address - Fax:
Practice Address - Street 1:601 EDGEWOOD ST NE APT 309
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20017-3317
Practice Address - Country:US
Practice Address - Phone:202-910-9800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-20
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC200002419374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC70052787Medicaid