1720061351 NPI number — MRS. LAURIE JOHNSON PT

Table of content: MRS. LAURIE JOHNSON PT (NPI 1720061351)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720061351 NPI number — MRS. LAURIE JOHNSON PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
LAURIE
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720061351
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/22/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5982
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VIRGINIA BEACH
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23471-0982
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-351-6020
Provider Business Mailing Address Fax Number:
757-351-6021

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5665 LOWERY RD
Provider Second Line Business Practice Location Address:
#300
Provider Business Practice Location Address City Name:
NORFOLK
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23502-2220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-351-6020
Provider Business Practice Location Address Fax Number:
757-351-6021
Provider Enumeration Date:
11/29/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  2305003714 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 010380740 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 010380758 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 010381207 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 010380766 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 010381223 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 008938741 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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