Provider Demographics
NPI:1366738411
Name:JOHNSON, DARAYON DAVON
Entity type:Individual
Prefix:MR
First Name:DARAYON
Middle Name:DAVON
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 1:6236 DIAZO ST
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89031-1727
Mailing Address - Country:US
Mailing Address - Phone:702-376-7914
Mailing Address - Fax:
Practice Address - Street 1:2349 RENAISSANCE DR
Practice Address - Street 2:SUITE A
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-6191
Practice Address - Country:US
Practice Address - Phone:702-739-7716
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-27
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner