Basic Information
| Provider Information | |||||||||
| NPI: | 1295184737 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | LIANA | ||||||||
| MiddleName: | MICHELLE | ||||||||
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| OtherLastName: | FLY | ||||||||
| OtherFirstName: | LIANA | ||||||||
| OtherMiddleName: | MICHELLE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 220 VERDE ST | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234624419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109488330 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4092 FOXWOOD DR | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234625225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574674200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2016 | ||||||||
| LastUpdateDate: | 06/06/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.