Provider Demographics
NPI:1164826400
Name:JOHNSON, DEANTWANN
Entity Type:Individual
Prefix:
First Name:DEANTWANN
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1170 N SAN ANTONIO AVE
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-4104
Mailing Address - Country:US
Mailing Address - Phone:909-446-9440
Mailing Address - Fax:
Practice Address - Street 1:1126 W FOOTHILL BLVD
Practice Address - Street 2:SUITE 150
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-3768
Practice Address - Country:US
Practice Address - Phone:909-982-8641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-15
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker