Provider Demographics
NPI:1114717733
Name:JOHNSON, BRUCE
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:
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 1:7493 E DANUBE LOOP
Mailing Address - Street 2:
Mailing Address - City:NEW KENT
Mailing Address - State:VA
Mailing Address - Zip Code:23124-2636
Mailing Address - Country:US
Mailing Address - Phone:804-943-8735
Mailing Address - Fax:804-932-0010
Practice Address - Street 1:7493 E DANUBE LOOP
Practice Address - Street 2:
Practice Address - City:NEW KENT
Practice Address - State:VA
Practice Address - Zip Code:23124-2636
Practice Address - Country:US
Practice Address - Phone:804-943-8735
Practice Address - Fax:804-932-0010
Is Sole Proprietor?:No
Enumeration Date:2025-05-07
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376G00000XNursing Service Related ProvidersNursing Home Administrator