Provider Demographics
NPI:1124807557
Name:JOHNSON, SAMANTHA R (CERTIFIED NURSE ASSI)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:R
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CERTIFIED NURSE ASSI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:929 N GRAHAM AVE
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-3341
Mailing Address - Country:US
Mailing Address - Phone:336-276-5595
Mailing Address - Fax:
Practice Address - Street 1:929 N GRAHAM AVE
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-3341
Practice Address - Country:US
Practice Address - Phone:336-276-5595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND246762374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide