Healthcare Provider Details

I. General information

NPI: 1568959856
Provider Name (Legal Business Name): MOREEN JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2018
Last Update Date: 04/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CHRISTIAN NURSING REGISTRY 17 BANK AVE
SMITH TOWN NY
11787
US

IV. Provider business mailing address

CHRISTIAN NURSING REGISTRY 17 BANK AVE
SMITH TOWN NY
11787
US

V. Phone/Fax

Practice location:
  • Phone: 631-265-5300
  • Fax:
Mailing address:
  • Phone: 631-265-5300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number714762
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: