Healthcare Provider Details

I. General information

NPI: 1578185369
Provider Name (Legal Business Name): MARION JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2020
Last Update Date: 05/14/2020
Certification Date: 05/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9633 CLOCKTOWER LN
COLUMBIA MD
21046-1877
US

IV. Provider business mailing address

9633 CLOCKTOWER LN
COLUMBIA MD
21046-1877
US

V. Phone/Fax

Practice location:
  • Phone: 240-535-6111
  • Fax:
Mailing address:
  • Phone: 240-535-6111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberR187659
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number1040399
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: