Basic Information
Provider Information | |||||||||
NPI: | 1538387089 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JOHNSON | ||||||||
FirstName: | SHERRI | ||||||||
MiddleName: | LYNNE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 88 | ||||||||
Address2: | 5 E ALVON ROAD STE 7 | ||||||||
City: | WHITE SULPHUR SPRINGS | ||||||||
State: | WV | ||||||||
PostalCode: | 249860088 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3045365030 | ||||||||
FaxNumber: | 3045365031 | ||||||||
Practice Location | |||||||||
Address1: | 2900 1ST AVE | ||||||||
Address2: | ROOM 1025 | ||||||||
City: | HUNTINGTON | ||||||||
State: | WV | ||||||||
PostalCode: | 257021241 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3043997484 | ||||||||
FaxNumber: | 3043997579 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/22/2007 | ||||||||
LastUpdateDate: | 04/25/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 22733 | WV | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 1073741 | 01 | WV | BRICKSTREET | OTHER | 3810009488 | 05 | WV |   | MEDICAID | 000000246103 | 01 | OH | UNISON/OHIO/HMO | OTHER | 2789504 | 05 | OH |   | MEDICAID | 2177885 | 01 | WV | UHC | OTHER | 001910394 | 01 | WV | MTN STATE BCBS | OTHER | 1314987 | 01 | WV | CIGNA | OTHER | 7100022180 | 05 | KY |   | MEDICAID |