Provider Demographics
NPI:1053717082
Name:JOHNSON, VINCENT BERNARD (APRN)
Entity type:Individual
Prefix:
First Name:VINCENT
Middle Name:BERNARD
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3310 MAGNOLIA ST
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29115-1466
Mailing Address - Country:US
Mailing Address - Phone:803-531-6900
Mailing Address - Fax:
Practice Address - Street 1:3310 MAGNOLIA ST
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-1466
Practice Address - Country:US
Practice Address - Phone:803-531-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-19
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19182363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP3041Medicaid
SCSC48557819Medicare PIN
SCSC48555281Medicare PIN
SCSC48555282Medicare PIN
SCSC48557006Medicare PIN
SCSC48557126Medicare PIN
SCSC48557522Medicare PIN
SCSC48556834Medicare PIN
SCSC48557499Medicare PIN
SCSC48556868Medicare PIN
SCSC48558798Medicare PIN
SCNP3041Medicaid
SCSC48557498Medicare PIN
SCSC48557555Medicare PIN
SCSC48555277Medicare PIN