MEDICARE: EDWARD JOHNSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	R189350	MD

General Provider Information

NPI Number	:	1467811109
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDWARD JOHNSON

Provider Business Mailing Address
First Line	:	1755 SHARWOOD PL
Second Line	:
City	:	CROFTON
State	:	MD
Zip	:	21114-1924
Country	:	US
Telephone Number	:	410-533-6316
Fax Number	:

Provider Business Practice Location Address
First Line	:	9055 CHEVROLET DR
Second Line	:
City	:	ELLICOTT CITY
State	:	MD
Zip	:	21042-4016
Country	:	US
Telephone Number	:	410-878-2887
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/22/2016
Last Update Date	:	02/22/2016

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