Provider Demographics
NPI:1164783171
Name:JOHNSON, LAURA VANESSA (AUD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:VANESSA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 N PHOENIX AVE
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-2825
Mailing Address - Country:US
Mailing Address - Phone:479-886-0908
Mailing Address - Fax:
Practice Address - Street 1:221 N PHOENIX AVE
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-2825
Practice Address - Country:US
Practice Address - Phone:479-886-0908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-06
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR380231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist