Provider Demographics
NPI:1871622100
Name:JOHNSON-VANN, PEARL TERESA (PT)
Entity type:Individual
Prefix:
First Name:PEARL
Middle Name:TERESA
Last Name:JOHNSON-VANN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:TERRY
Other - Middle Name:
Other - Last Name:JOHNSON-VANN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:3504 OLIVE BRANCH DR
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904-4907
Mailing Address - Country:US
Mailing Address - Phone:301-890-4976
Mailing Address - Fax:
Practice Address - Street 1:407 CHURCH ST NE STE D
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22180-4737
Practice Address - Country:US
Practice Address - Phone:703-242-1921
Practice Address - Fax:703-242-1922
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA23050039572251P0200X
MD163512251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
188033Medicare UPIN
376530Medicare UPIN