Provider Demographics
NPI:1194362780
Name:JOHNSON, JUDY (LAC)
Entity type:Individual
Prefix:
First Name:JUDY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12230 CLARKSVILLE PIKE STE I
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21029-1477
Mailing Address - Country:US
Mailing Address - Phone:443-712-7212
Mailing Address - Fax:
Practice Address - Street 1:12230 CLARKSVILLE PIKE STE I
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21029-1477
Practice Address - Country:US
Practice Address - Phone:443-712-7212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-03
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU02532171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist