Provider Demographics
NPI:1558180455
Name:JOHNSON, FREDRICKLYN EDWINA
Entity type:Individual
Prefix:
First Name:FREDRICKLYN
Middle Name:EDWINA
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 1:13113 CAMERON GROVE LOOP APT 307
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-2825
Mailing Address - Country:US
Mailing Address - Phone:617-309-6716
Mailing Address - Fax:
Practice Address - Street 1:13113 CAMERON GROVE LOOP APT 307
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-2825
Practice Address - Country:US
Practice Address - Phone:617-309-6716
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-08
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor