Basic Information
| Provider Information | |||||||||
| NPI: | 1194029397 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | RACHAEL | ||||||||
| MiddleName: | LOTTIE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CRNP-F | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FREDERICK | ||||||||
| OtherFirstName: | RACHAEL | ||||||||
| OtherMiddleName: | LOTTIE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 11350 MCCORMICK RD | ||||||||
| Address2: | EXECUTIVE PLAZA 1, SUITE 501 | ||||||||
| City: | HUNT VALLEY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210311002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016659696 | ||||||||
| FaxNumber: | 2404205715 | ||||||||
| Practice Location | |||||||||
| Address1: | 1150 PROFESSIONAL CT | ||||||||
| Address2: | SUITE P | ||||||||
| City: | HAGERSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217404100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016659696 | ||||||||
| FaxNumber: | 2404205715 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2011 | ||||||||
| LastUpdateDate: | 02/21/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R224985 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.