Healthcare Provider Details

I. General information

NPI: 1639683048
Provider Name (Legal Business Name): REBECCA ANN JOHNSON CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2017
Last Update Date: 11/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

747 NORTHERN AVE
HAGERSTOWN MD
21742-2723
US

IV. Provider business mailing address

9910 BROWNS MILL RD
GREENCASTLE PA
17225-9705
US

V. Phone/Fax

Practice location:
  • Phone: 301-791-6360
  • Fax:
Mailing address:
  • Phone: 717-658-3852
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberR149871
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: