1770773749 NPI number — MISS CONNIE D HABERSHAM-JOHNSON LPN

Table of content: MISS CONNIE D HABERSHAM-JOHNSON LPN (NPI 1770773749)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770773749 NPI number — MISS CONNIE D HABERSHAM-JOHNSON LPN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HABERSHAM-JOHNSON
Provider First Name:
CONNIE
Provider Middle Name:
D
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
LPN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HABERSHAM
Provider Other First Name:
CONNIE
Provider Other Middle Name:
D
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1770773749
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/25/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
261 CONNECTICUT DR
Provider Second Line Business Mailing Address:
STE 5
Provider Business Mailing Address City Name:
BURLINGTON
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08016-0151
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-785-8109
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2250 HICKORY RD
Provider Second Line Business Practice Location Address:
SUITE 216
Provider Business Practice Location Address City Name:
PLYMOUTH
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19462
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-950-6066
Provider Business Practice Location Address Fax Number:
609-387-7540
Provider Enumeration Date:
07/26/2007

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: 164W00000X , with the licence number:  26NP03799200 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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