Healthcare Provider Details

I. General information

NPI: 1285370874
Provider Name (Legal Business Name): SONSERAY D JOHNSON PBT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2022
Last Update Date: 05/07/2022
Certification Date: 05/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7950 CROSSROADS DR APT 113
NORTH CHARLESTON SC
29406-9414
US

IV. Provider business mailing address

2139 TARGET ST
NORTH CHARLESTON SC
29406-6263
US

V. Phone/Fax

Practice location:
  • Phone: 888-910-0573
  • Fax:
Mailing address:
  • Phone: 843-374-9084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: