Healthcare Provider Details

I. General information

NPI: 1093123069
Provider Name (Legal Business Name): COURTNY JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2014
Last Update Date: 12/16/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 CHALKSTONE AVE
PROVIDENCE RI
02908-4728
US

IV. Provider business mailing address

825 CHALKSTONE AVE
PROVIDENCE RI
02908-4728
US

V. Phone/Fax

Practice location:
  • Phone: 401-456-2000
  • Fax:
Mailing address:
  • Phone: 401-456-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberLPR00142
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: