Provider Demographics
NPI:1386118289
Name:JOHNSON, DIA LYNAE (CRNP)
Entity type:Individual
Prefix:MRS
First Name:DIA
Middle Name:LYNAE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4101 GLENHUNT RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21229-1705
Mailing Address - Country:US
Mailing Address - Phone:443-558-8532
Mailing Address - Fax:
Practice Address - Street 1:4101 GLENHUNT RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229-1705
Practice Address - Country:US
Practice Address - Phone:443-558-8532
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-14
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR202400363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health