Basic Information
| Provider Information | |||||||||
| NPI: | 1821678889 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | KEITH | ||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KEITH | ||||||||
| OtherFirstName: | REBECCA | ||||||||
| OtherMiddleName: | ASHLEY | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 914 ORAPAX ST APT G | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235071357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403131096 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 600 GRESHAM DR STE 304 | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235071904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573883397 | ||||||||
| FaxNumber: | 7573882885 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2021 | ||||||||
| LastUpdateDate: | 04/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/13/2021 | ||||||||
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.