Provider Demographics
NPI:1861526683
Name:JOHNSON, MARY-MARTHA (MSN,APRN,BC)
Entity type:Individual
Prefix:MRS
First Name:MARY-MARTHA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MSN,APRN,BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8218 WESTMINSTER RD
Mailing Address - Street 2:
Mailing Address - City:ELKINS PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19027-1409
Mailing Address - Country:US
Mailing Address - Phone:215-572-6326
Mailing Address - Fax:215-885-2808
Practice Address - Street 1:555 E CITY AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:BALA CYNWYD
Practice Address - State:PA
Practice Address - Zip Code:19004-1115
Practice Address - Country:US
Practice Address - Phone:610-660-8338
Practice Address - Fax:610-660-8339
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN242205L163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA047305M7XMedicare ID - Type Unspecified
PAP30165Medicare UPIN