Provider Demographics
NPI:1750751350
Name:JOHNSON, DAVA
Entity type:Individual
Prefix:
First Name:DAVA
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 1:215 WALTERSCHEID BLVD
Mailing Address - Street 2:APT I 103
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82007-2333
Mailing Address - Country:US
Mailing Address - Phone:479-313-2604
Mailing Address - Fax:
Practice Address - Street 1:215 WALTERSCHEID BLVD
Practice Address - Street 2:APT I 103
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82007-2333
Practice Address - Country:US
Practice Address - Phone:479-313-2604
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-25
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator