Provider Demographics
NPI:1366203721
Name:JOHNSON, HEATHER
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 JACK BURLINGAME DR
Mailing Address - Street 2:
Mailing Address - City:MILLWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:25262-8576
Mailing Address - Country:US
Mailing Address - Phone:304-273-9311
Mailing Address - Fax:
Practice Address - Street 1:270 JACK BURLINGAME DR
Practice Address - Street 2:
Practice Address - City:MILLWOOD
Practice Address - State:WV
Practice Address - Zip Code:25262-8576
Practice Address - Country:US
Practice Address - Phone:304-273-9311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-22
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3747P1801X
WV3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant