Healthcare Provider Details

I. General information

NPI: 1306005087
Provider Name (Legal Business Name): MS. SUNDRA RENEE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2008
Last Update Date: 06/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 26TH ST 1414 26TH STREET
TUSCALOOSA AL
35401-6642
US

IV. Provider business mailing address

1414 26TH ST 1414 26TH STREET
TUSCALOOSA AL
35401-6642
US

V. Phone/Fax

Practice location:
  • Phone: 205-752-6081
  • Fax:
Mailing address:
  • Phone: 205-752-6081
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number102375
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: