Provider Demographics
NPI:1669283552
Name:JOHNSON, TEQUILA
Entity type:Individual
Prefix:MS
First Name:TEQUILA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3093 SAWTOOTH DR
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32303-7375
Mailing Address - Country:US
Mailing Address - Phone:862-236-8458
Mailing Address - Fax:
Practice Address - Street 1:3093 SAWTOOTH DR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32303-7375
Practice Address - Country:US
Practice Address - Phone:850-755-0612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-18
Last Update Date:2025-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
343900000X
FL347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)