Provider Demographics
NPI:1134617046
Name:JOHNSON, RODNEY JAMAR (RN)
Entity type:Individual
Prefix:
First Name:RODNEY
Middle Name:JAMAR
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14384 W MAUI LN
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85379-8529
Mailing Address - Country:US
Mailing Address - Phone:623-556-9009
Mailing Address - Fax:
Practice Address - Street 1:14384 W MAUI LN
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85379-8529
Practice Address - Country:US
Practice Address - Phone:623-556-9009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-25
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL10660H310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ360398Medicaid