Provider Demographics
NPI:1578399978
Name:BONSRAH, JOHNSON
Entity type:Individual
Prefix:
First Name:JOHNSON
Middle Name:
Last Name:BONSRAH
Suffix:
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 1:39 TYSON RD # 1
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01606-1124
Mailing Address - Country:US
Mailing Address - Phone:774-267-1244
Mailing Address - Fax:
Practice Address - Street 1:39 TYSON RD # 1
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01606-1124
Practice Address - Country:US
Practice Address - Phone:774-267-1244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-11
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALN99922164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse