Provider Demographics
NPI:1396182069
Name:JOHNSON, REBECCA CAROL
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:CAROL
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 281
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OK
Mailing Address - Zip Code:73724-0281
Mailing Address - Country:US
Mailing Address - Phone:580-886-2339
Mailing Address - Fax:580-886-2339
Practice Address - Street 1:311 WEST MAIN ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OK
Practice Address - Zip Code:73724
Practice Address - Country:US
Practice Address - Phone:580-886-2339
Practice Address - Fax:580-886-2339
Is Sole Proprietor?:No
Enumeration Date:2013-06-04
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker