Provider Demographics
NPI:1417761602
Name:JOHNSON, IMANI
Entity type:Individual
Prefix:
First Name:IMANI
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 1:1200 GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:SHADY SIDE
Mailing Address - State:MD
Mailing Address - Zip Code:20764-9536
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1200 GROVE AVE
Practice Address - Street 2:
Practice Address - City:SHADY SIDE
Practice Address - State:MD
Practice Address - Zip Code:20764-9536
Practice Address - Country:US
Practice Address - Phone:323-629-5749
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-06
Last Update Date:2025-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program