Provider Demographics
NPI:1376947457
Name:JOHNSON, TAMIKA
Entity Type:Individual
Prefix:
First Name:TAMIKA
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:PO BOX 1352
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:MS
Mailing Address - Zip Code:38879-1352
Mailing Address - Country:US
Mailing Address - Phone:662-308-8326
Mailing Address - Fax:
Practice Address - Street 1:158 MATTOX RD
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-9140
Practice Address - Country:US
Practice Address - Phone:662-308-8326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-17
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion