Individual
DEONDRE M JOHNSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
402 E COLLEGE ST, BRIDGEWATER, VA 22812-1511
(919) 527-4148
Mailing address
5009 C AND L AVE, WAKE FOREST, NC 27587-6355
(919) 527-4148
Taxonomy
Speciality
Code
Description
License number
State
390200000X
Student in an Organized Health Care Education/Training Program
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
U6174564304
CIGNA
—
Enumeration date
09/02/2019
Last updated
09/02/2019
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