Provider Demographics
NPI:1336835701
Name:SMITH, JOHNANNA (LICENCE)
Entity type:Individual
Prefix:
First Name:JOHNANNA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:LICENCE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1912 E NC HIGHWAY 54
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-2235
Mailing Address - Country:US
Mailing Address - Phone:919-949-5592
Mailing Address - Fax:
Practice Address - Street 1:1912 E HWY NC 54 SUITE 100
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713
Practice Address - Country:US
Practice Address - Phone:919-949-5592
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-18
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC410801744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management