Provider Demographics
NPI:1285229286
Name:JOHNNIE, CLARISSA MARIE
Entity Type:Individual
Prefix:
First Name:CLARISSA
Middle Name:MARIE
Last Name:JOHNNIE
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 1:3910 TREADWAY RD APT 803
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77706-7137
Mailing Address - Country:US
Mailing Address - Phone:409-433-7433
Mailing Address - Fax:
Practice Address - Street 1:9185 MONICA ST
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77707-4635
Practice Address - Country:US
Practice Address - Phone:409-433-7433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-02
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX340841164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse