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General NPI Number Information
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NPI Number | 1720396732
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Entity Type | Individual
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Provider Name | SERENA DENISE JOHNSON LPT
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Gender | Female
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Dates
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Enumeration Date | 09/24/2010
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Last Update Date | 09/24/2010
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Provider Practice Location Address
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Address Line | 5151A WALNUT STREET
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City | PHILADELPHIA
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State | PA
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Zip | 19139
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Country | US
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Telephone | 610-733-7539
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Fax | 215-878-8870
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Provider Business Mailing Address
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Address Line | 3900 FORD RD 14A
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City | PHILADELPHIA
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State | PA
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Zip | 19131-2039
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Country | US
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Telephone | 610-733-7539
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Fax | 215-878-8870
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171W00000X
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Taxonomy Name | Contractor
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License Number | PT006315L
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License Number State | PA
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