Provider Demographics
NPI:1275072035
Name:JOHNSON, LATIESE (RRT)
Entity Type:Individual
Prefix:
First Name:LATIESE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16450 W VAN BUREN ST APT 2017
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-1609
Mailing Address - Country:US
Mailing Address - Phone:313-482-8185
Mailing Address - Fax:
Practice Address - Street 1:16450 W VAN BUREN ST APT 2017
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-1609
Practice Address - Country:US
Practice Address - Phone:313-482-8185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-13
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0119252279G1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2279G1100XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, RegisteredGeneral Care