Healthcare Provider Details

I. General information

NPI: 1538514328
Provider Name (Legal Business Name): JOHNNIE WYATTE REID
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2016
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4727 ROSECROFT ST
VIRGINIA BEACH VA
23464-3029
US

IV. Provider business mailing address

4727 ROSECROFT ST
VIRGINIA BEACH VA
23464-3029
US

V. Phone/Fax

Practice location:
  • Phone: 757-816-0622
  • Fax: 757-467-5257
Mailing address:
  • Phone: 757-816-0622
  • Fax: 757-467-5257

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number420
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: