Healthcare Provider Details

I. General information

NPI: 1669635447
Provider Name (Legal Business Name): AVA C JOHNSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AVA JEAN COLE

II. Dates (important events)

Enumeration Date: 07/02/2008
Last Update Date: 07/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4049 MAIN ST
CHINCOTEAGUE VA
23336-2406
US

IV. Provider business mailing address

4049 MAIN ST
CHINCOTEAGUE VA
23336-2406
US

V. Phone/Fax

Practice location:
  • Phone: 757-336-3682
  • Fax: 757-336-3703
Mailing address:
  • Phone: 757-336-3682
  • Fax: 757-336-3703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024167876
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: