Provider Demographics
NPI:1255865747
Name:JOHNSON, TYRONE
Entity type:Individual
Prefix:
First Name:TYRONE
Middle Name:
Last Name:JOHNSON
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 1:2512 COUNTY ROAD U
Mailing Address - Street 2:
Mailing Address - City:LAMESA
Mailing Address - State:TX
Mailing Address - Zip Code:79331-7970
Mailing Address - Country:US
Mailing Address - Phone:903-722-3871
Mailing Address - Fax:
Practice Address - Street 1:2512 COUNTY ROAD U
Practice Address - Street 2:
Practice Address - City:LAMESA
Practice Address - State:TX
Practice Address - Zip Code:79331-7970
Practice Address - Country:US
Practice Address - Phone:903-722-3871
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-12
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX143199164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse