Provider Demographics
NPI:1083401483
Name:JOHNSON, MARIAH SAMUELLE
Entity type:Individual
Prefix:
First Name:MARIAH
Middle Name:SAMUELLE
Last Name:JOHNSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:357 NEWPORT AVE APT 4E
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02170-3359
Mailing Address - Country:US
Mailing Address - Phone:717-585-1427
Mailing Address - Fax:
Practice Address - Street 1:55 FOGG RD
Practice Address - Street 2:
Practice Address - City:SOUTH WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02190-2455
Practice Address - Country:US
Practice Address - Phone:781-624-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-21
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program