Healthcare Provider Details

I. General information

NPI: 1104096460
Provider Name (Legal Business Name): SOPHIA GELAJ JOHNSTON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2008
Last Update Date: 03/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 VELIE RD
LAGRANGEVILLE NY
12540-5516
US

IV. Provider business mailing address

PO BOX 436
STORMVILLE NY
12582-0436
US

V. Phone/Fax

Practice location:
  • Phone: 845-592-0619
  • Fax: 845-592-0619
Mailing address:
  • Phone: 845-592-0619
  • Fax: 845-592-0619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number444688-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: