Basic Information
| Provider Information | |||||||||
| NPI: | 1346729530 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | SYDNEY | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 829642 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191824735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8664706626 | ||||||||
| FaxNumber: | 4135990470 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 PLUM ST FL 5 | ||||||||
| Address2: | |||||||||
| City: | NEW BRUNSWICK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 089012066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322356333 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2018 | ||||||||
| LastUpdateDate: | 07/13/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | SP019044 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 14357115 | 01 | CAQH | OTHER |