Provider Demographics
NPI:1902120082
Name:JOHNSON, RENE (CRNP)
Entity type:Individual
Prefix:
First Name:RENE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:173 SAINT PATRICKS DR STE 104
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20603-5530
Mailing Address - Country:US
Mailing Address - Phone:888-731-8994
Mailing Address - Fax:
Practice Address - Street 1:173 SAINT PATRICKS DR STE 104
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20603-5530
Practice Address - Country:US
Practice Address - Phone:888-731-8994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-18
Last Update Date:2025-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR134332163W00000X, 363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD058443600Medicaid
MDG00121Medicare UPIN
MD254949ZAEMedicare PIN