Provider Demographics
NPI:1073975066
Name:JOHNSON, DERMAINE ANTWAN (CERTIFIED HAIR LOSS)
Entity Type:Individual
Prefix:MR
First Name:DERMAINE
Middle Name:ANTWAN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:CERTIFIED HAIR LOSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 HIGHWAY 39 N APT 77
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-1339
Mailing Address - Country:US
Mailing Address - Phone:334-505-7628
Mailing Address - Fax:
Practice Address - Street 1:3500 HIGHWAY 39 N APT 77
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-1339
Practice Address - Country:US
Practice Address - Phone:334-505-7628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-28
Last Update Date:2016-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS50551744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management