Healthcare Provider Details

I. General information

NPI: 1871898460
Provider Name (Legal Business Name): DIANE LAVERNE JOHNSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2011
Last Update Date: 01/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 W PRATT ST
BALTIMORE MD
21201-1023
US

IV. Provider business mailing address

701 W PRATT ST
BALTIMORE MD
21201-1023
US

V. Phone/Fax

Practice location:
  • Phone: 410-328-2564
  • Fax: 410-328-0096
Mailing address:
  • Phone: 410-328-2564
  • Fax: 410-328-0096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberR105143
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: