Provider Demographics
NPI:1407205529
Name:JOHNSON, FELICIA
Entity Type:Individual
Prefix:
First Name:FELICIA
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 1:1764 THUNDERBIRD AVE
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63033
Mailing Address - Country:US
Mailing Address - Phone:314-274-8484
Mailing Address - Fax:314-274-8585
Practice Address - Street 1:1764 THUNDERBIRD AVE
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63033
Practice Address - Country:US
Practice Address - Phone:314-274-8484
Practice Address - Fax:314-274-8585
Is Sole Proprietor?:No
Enumeration Date:2016-06-09
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician