Provider Demographics
NPI:1275806010
Name:JOHNSON, LANCE CORDELL
Entity Type:Individual
Prefix:
First Name:LANCE
Middle Name:CORDELL
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 1:7508 S LINN AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73159-4612
Mailing Address - Country:US
Mailing Address - Phone:405-443-1481
Mailing Address - Fax:
Practice Address - Street 1:7908 NW 23RD ST
Practice Address - Street 2:
Practice Address - City:BETHANY
Practice Address - State:OK
Practice Address - Zip Code:73008-4950
Practice Address - Country:US
Practice Address - Phone:405-636-1463
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-09
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)