Provider Demographics
NPI:1114434065
Name:JOHNSON, YETTA
Entity Type:Individual
Prefix:
First Name:YETTA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:YETTA
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:19002 DALLAS PKWY APT 1838
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75287-3160
Mailing Address - Country:US
Mailing Address - Phone:214-931-4595
Mailing Address - Fax:
Practice Address - Street 1:19002 DALLAS PKWY APT 1838
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75287-3160
Practice Address - Country:US
Practice Address - Phone:214-931-4595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-01
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374U00000X, 332U00000X, 171M00000X
TX332B00000X, 374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332U00000XSuppliersHome Delivered Meals
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX081097943OtherDUNS NUMBER