Provider Demographics
NPI:1366937690
Name:JOHNSON-WILLIAMS, MARQUISHA LAVONE (RN)
Entity type:Individual
Prefix:
First Name:MARQUISHA
Middle Name:LAVONE
Last Name:JOHNSON-WILLIAMS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7604 BERMEJO RD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76112-6108
Mailing Address - Country:US
Mailing Address - Phone:817-683-3936
Mailing Address - Fax:
Practice Address - Street 1:7604 BERMEJO RD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76112-6108
Practice Address - Country:US
Practice Address - Phone:817-683-3936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-28
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX714040163WC1500X
320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental DisabilitiesGroup - Multi-Specialty
No163WC1500XNursing Service ProvidersRegistered NurseCommunity HealthGroup - Multi-Specialty