MEDICARE: PRINCESS JOHNSON JR.

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	376G00000X	Nursing Home Administrator	347005264	CA
2	376K00000X	Nurse's Aide	00648092	CA

General Provider Information

NPI Number	:	1912300922
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PRINCESS JOHNSON JR.

Provider Business Mailing Address
First Line	:	407 MAPLE ST
Second Line	:
City	:	GALT
State	:	CA
Zip	:	95632-2048
Country	:	US
Telephone Number	:	916-821-2391
Fax Number	:	209-912-4141

Provider Business Practice Location Address
First Line	:	407 MAPLE ST
Second Line	:
City	:	GALT
State	:	CA
Zip	:	95632-2048
Country	:	US
Telephone Number	:	916-821-2391
Fax Number	:	209-912-4141

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

Provider Enumeration Date	:	10/04/2014
Last Update Date	:	10/04/2014

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