Provider Demographics
NPI:1811582315
Name:JOHNSON, CARMEN E (CERTIFIED HAIR LOSS)
Entity type:Individual
Prefix:MRS
First Name:CARMEN
Middle Name:E
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CERTIFIED HAIR LOSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 DOMINION CT
Mailing Address - Street 2:
Mailing Address - City:CAMERON
Mailing Address - State:NC
Mailing Address - Zip Code:28326-9814
Mailing Address - Country:US
Mailing Address - Phone:910-489-7950
Mailing Address - Fax:
Practice Address - Street 1:220 N MCPHERSON CHURCH RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-4495
Practice Address - Country:US
Practice Address - Phone:910-489-7950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-05
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC1744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1835X0200XOtherONCOLOGY
NC207N00000XOtherDERMATOLOGY