Provider Demographics
NPI:1346696200
Name:JOHNSON, DESIRRAY
Entity Type:Individual
Prefix:
First Name:DESIRRAY
Middle Name:
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:P.O. BOX 2266
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE VIEW
Mailing Address - State:TX
Mailing Address - Zip Code:77446
Mailing Address - Country:US
Mailing Address - Phone:832-368-0792
Mailing Address - Fax:
Practice Address - Street 1:43702 HWY BUSINESS 290
Practice Address - Street 2:
Practice Address - City:WALLER
Practice Address - State:TX
Practice Address - Zip Code:77484
Practice Address - Country:US
Practice Address - Phone:832-368-0792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-10
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program