Healthcare Provider Details

I. General information

NPI: 1386750768
Provider Name (Legal Business Name): DEBORAH JEAN JOHNSON RPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

324 UNIVERSITY AVE
SYRACUSE NY
13210-1811
US

IV. Provider business mailing address

PO BOX 664
BREWERTON NY
13029-0664
US

V. Phone/Fax

Practice location:
  • Phone: 315-472-4471
  • Fax:
Mailing address:
  • Phone: 315-668-8176
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number359751
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: