Basic Information
| Provider Information | |||||||||
| NPI: | 1457970360 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | TAYLOR | ||||||||
| MiddleName: | RENEE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 311 CARAWAY DR | ||||||||
| Address2: | |||||||||
| City: | BEAR | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197016013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6099700343 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1800 LOMBARD ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191461414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007897366 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2020 | ||||||||
| LastUpdateDate: | 04/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.