MEDICARE: LAVERNE JOHNSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	374J00000X	Doula

General Provider Information

NPI Number	:	1588304257
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAVERNE JOHNSON

Provider Business Mailing Address
First Line	:	PO BOX 549
Second Line	:
City	:	GLOUCESTER CITY
State	:	NJ
Zip	:	08030-0549
Country	:	US
Telephone Number	:	610-818-5735
Fax Number	:

Provider Business Practice Location Address
First Line	:	2634 W ARIZONA ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19132-4621
Country	:	US
Telephone Number	:	610-818-5735
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/31/2022
Last Update Date	:	03/31/2022

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