Healthcare Provider Details

I. General information

NPI: 1548350291
Provider Name (Legal Business Name): TAMI JOHNSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 02/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 ELDERT STREET
BROOKLYN NY
11267
US

IV. Provider business mailing address

POB 380593 ADELPHI STATION
BROOKLYN NY
11238
US

V. Phone/Fax

Practice location:
  • Phone: 347-365-7962
  • Fax: 718-390-8929
Mailing address:
  • Phone: 347-365-7962
  • Fax: 718-390-8929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number9582L001
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number
License Number State

VIII. Authorized Official

Name: MS. TAMI N JOHNSON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 347-365-7962