Provider Demographics
NPI:1417541442
Name:HOWARD, JOHNNY L JR
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:L
Last Name:HOWARD
Suffix:JR
Gender:M
Credentials:
Other - Prefix:MRS
Other - First Name:DOMINIQUE
Other - Middle Name:L
Other - Last Name:HOWARD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:5232 S KINGSHIGHWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63109-2923
Mailing Address - Country:US
Mailing Address - Phone:314-223-6191
Mailing Address - Fax:
Practice Address - Street 1:5232 S KINGSHIGHWAY BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63109-2923
Practice Address - Country:US
Practice Address - Phone:314-223-6191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-20
Last Update Date:2021-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO86-2055323Medicaid