Provider Demographics
NPI:1588056261
Name:JOHNSON, CONNIE
Entity type:Individual
Prefix:
First Name:CONNIE
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 1:862 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:HILLSBOROUGH
Mailing Address - State:NJ
Mailing Address - Zip Code:08844-3324
Mailing Address - Country:US
Mailing Address - Phone:609-216-3174
Mailing Address - Fax:
Practice Address - Street 1:862 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:HILLSBOROUGH
Practice Address - State:NJ
Practice Address - Zip Code:08844-3324
Practice Address - Country:US
Practice Address - Phone:609-216-3174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-04
Last Update Date:2015-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR13110100163WX1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WX1500XNursing Service ProvidersRegistered NurseOstomy Care