Provider Demographics
NPI:1093956823
Name:JOHNSON, REGINA ANNETTE
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:ANNETTE
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 1:709 GOLDWOOD DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75232-3955
Mailing Address - Country:US
Mailing Address - Phone:214-774-9463
Mailing Address - Fax:972-228-1628
Practice Address - Street 1:709 GOLDWOOD DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75232-3955
Practice Address - Country:US
Practice Address - Phone:214-774-9463
Practice Address - Fax:972-228-1628
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-06
Last Update Date:2009-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX012452251E00000X, 3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1760538052Medicaid