Provider Demographics
NPI:1174829055
Name:JOHNSON-MAYTUBBY, ERVINA MAE
Entity Type:Individual
Prefix:
First Name:ERVINA
Middle Name:MAE
Last Name:JOHNSON-MAYTUBBY
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 1:8828 OAKRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73110-7418
Mailing Address - Country:US
Mailing Address - Phone:214-854-8516
Mailing Address - Fax:
Practice Address - Street 1:8828 OAKRIDGE DR
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-7418
Practice Address - Country:US
Practice Address - Phone:214-854-8516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-10
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator