Healthcare Provider Details

I. General information

NPI: 1326470212
Provider Name (Legal Business Name): CHRISTINE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2013
Last Update Date: 08/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5710 PONY FARM DR APT 203
RICHMOND VA
23227-4905
US

IV. Provider business mailing address

5710 PONY FARM DR APT 203
RICHMOND VA
23227-4905
US

V. Phone/Fax

Practice location:
  • Phone: 732-619-9369
  • Fax:
Mailing address:
  • Phone: 732-619-9369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: