Provider Demographics
NPI:1982371621
Name:JOHNSON, DELORIS
Entity Type:Individual
Prefix:
First Name:DELORIS
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 1:2246 SALLY GAILLARD LN
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29466-8869
Mailing Address - Country:US
Mailing Address - Phone:254-415-0639
Mailing Address - Fax:
Practice Address - Street 1:3180 THOMASINA MCPHERSON BLVD
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29405-8283
Practice Address - Country:US
Practice Address - Phone:843-745-2184
Practice Address - Fax:843-745-2182
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-29
Last Update Date:2021-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC44895163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse