Provider Demographics
NPI:1063203099
Name:JOHNSON, THORNELL I
Entity type:Individual
Prefix:
First Name:THORNELL
Middle Name:
Last Name:JOHNSON
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:906 HICKORY CIR
Mailing Address - Street 2:
Mailing Address - City:LA PLATA
Mailing Address - State:MD
Mailing Address - Zip Code:20646-3213
Mailing Address - Country:US
Mailing Address - Phone:240-715-2852
Mailing Address - Fax:
Practice Address - Street 1:906 HICKORY CIR
Practice Address - Street 2:
Practice Address - City:LA PLATA
Practice Address - State:MD
Practice Address - Zip Code:20646-3213
Practice Address - Country:US
Practice Address - Phone:240-715-2852
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-17
Last Update Date:2025-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLP53308164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse