Provider Demographics
NPI:1043677222
Name:JOHNSON, TABATHA
Entity Type:Individual
Prefix:MISS
First Name:TABATHA
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:PO BOX 11058
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77293-1058
Mailing Address - Country:US
Mailing Address - Phone:832-283-3102
Mailing Address - Fax:
Practice Address - Street 1:15100 ELLA BLVD APT 708
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77090-7033
Practice Address - Country:US
Practice Address - Phone:832-283-3102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-19
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP130052363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care