Provider Demographics
NPI:1174031884
Name:JOHNSON, CLAUDETTE ELIZABETH
Entity Type:Individual
Prefix:
First Name:CLAUDETTE
Middle Name:ELIZABETH
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 1:21181 N GRANTHAM RD
Mailing Address - Street 2:
Mailing Address - City:MARICOPA
Mailing Address - State:AZ
Mailing Address - Zip Code:85138-6655
Mailing Address - Country:US
Mailing Address - Phone:719-464-9552
Mailing Address - Fax:
Practice Address - Street 1:21181 N GRANTHAM RD
Practice Address - Street 2:
Practice Address - City:MARICOPA
Practice Address - State:AZ
Practice Address - Zip Code:85138-6655
Practice Address - Country:US
Practice Address - Phone:719-464-9552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-16
Last Update Date:2018-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8723402171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor