Healthcare Provider Details

I. General information

NPI: 1669654604
Provider Name (Legal Business Name): MARIA TERSEA JOHNSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2007
Last Update Date: 12/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 BENSON ST
ALBANY NY
12206-2122
US

IV. Provider business mailing address

1137 RAYMOND RD
BALLSTON SPA NY
12020-3719
US

V. Phone/Fax

Practice location:
  • Phone: 518-365-0018
  • Fax:
Mailing address:
  • Phone: 518-365-0018
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number517109
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: