Provider Demographics
NPI:1669754438
Name:JOHNSON, JOHNNY EDWARD JR
Entity type:Individual
Prefix:MR
First Name:JOHNNY
Middle Name:EDWARD
Last Name:JOHNSON
Suffix:JR
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 1:8040 MAPLE PARK ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89131-5289
Mailing Address - Country:US
Mailing Address - Phone:702-858-8884
Mailing Address - Fax:702-586-3334
Practice Address - Street 1:8040 MAPLE PARK ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89131-5289
Practice Address - Country:US
Practice Address - Phone:702-858-8884
Practice Address - Fax:702-586-3334
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-16
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner