MEDICARE: MAE JOHNSON RN

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	163W00000X	Registered Nurse	26NO12345100	NJ

General Provider Information

NPI Number	:	1588817035
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAE JOHNSON RN

Provider Business Mailing Address
First Line	:	18 BRIDLE PATH CT
Second Line	:
City	:	SICKLERVILLE
State	:	NJ
Zip	:	08081-5645
Country	:	US
Telephone Number	:	800-950-6066
Fax Number	:

Provider Business Practice Location Address
First Line	:	18 BRIDLE PATH CT
Second Line	:
City	:	SICKLERVILLE
State	:	NJ
Zip	:	08081-5645
Country	:	US
Telephone Number	:	800-950-6066
Fax Number	:

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

Provider Enumeration Date	:	10/28/2008
Last Update Date	:	10/28/2008

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