Healthcare Provider Details

I. General information

NPI: 1912314964
Provider Name (Legal Business Name): VIDAH JOHNSTON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2014
Last Update Date: 07/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 17TH ST
OAKLAND CA
94612-1553
US

IV. Provider business mailing address

513 FRUMENTI COURT
MARTINEZ CA
94553
US

V. Phone/Fax

Practice location:
  • Phone: 510-318-7119
  • Fax:
Mailing address:
  • Phone: 925-699-6564
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number708803
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: