Healthcare Provider Details

I. General information

NPI: 1912300922
Provider Name (Legal Business Name): PRINCESS JOHNSON JR.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2014
Last Update Date: 10/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 MAPLE ST
GALT CA
95632-2048
US

IV. Provider business mailing address

407 MAPLE ST
GALT CA
95632-2048
US

V. Phone/Fax

Practice location:
  • Phone: 916-821-2391
  • Fax: 209-912-4141
Mailing address:
  • Phone: 916-821-2391
  • Fax: 209-912-4141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376G00000X
TaxonomyNursing Home Administrator
License Number347005264
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number00648092
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: