Healthcare Provider Details

I. General information

NPI: 1942129432
Provider Name (Legal Business Name): JOHNNYMIKE LEANDER JOHNSON PRSS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2026
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2333 MACCORKLE AVE STE 201
SAINT ALBANS WV
25177-2074
US

IV. Provider business mailing address

2333 MACCORKLE AVE STE 201
SAINT ALBANS WV
25177-2074
US

V. Phone/Fax

Practice location:
  • Phone: 304-766-0060
  • Fax:
Mailing address:
  • Phone: 304-766-0060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number26982
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: