Healthcare Provider Details

I. General information

NPI: 1720396732
Provider Name (Legal Business Name): SERENA DENISE JOHNSON LPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2010
Last Update Date: 09/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5151A WALNUT STREET
PHILADELPHIA PA
19139
US

IV. Provider business mailing address

3900 FORD RD 14A
PHILADELPHIA PA
19131-2039
US

V. Phone/Fax

Practice location:
  • Phone: 610-733-7539
  • Fax: 215-878-8870
Mailing address:
  • Phone: 610-733-7539
  • Fax: 215-878-8870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License NumberPT006315L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: