Provider Demographics
NPI:1154743342
Name:JOHNSON, ANGELA
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27A DOWSING AVE
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-4118
Mailing Address - Country:US
Mailing Address - Phone:770-899-2226
Mailing Address - Fax:
Practice Address - Street 1:27A DOWSING AVENUE
Practice Address - Street 2:
Practice Address - City:BAYSHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-6013
Practice Address - Country:US
Practice Address - Phone:770-899-2226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-08
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN072931164W00000X
NY284163-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse