Provider Demographics
NPI:1437760444
Name:TOLER, JOHNNY ALEX
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:ALEX
Last Name:TOLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:562 TWILIGHT BLUE AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89032-8227
Mailing Address - Country:US
Mailing Address - Phone:323-218-1535
Mailing Address - Fax:
Practice Address - Street 1:562 TWILIGHT BLUE AVE
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032-8227
Practice Address - Country:US
Practice Address - Phone:323-218-1535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-13
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVCNA034060376K00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
No376K00000XNursing Service Related ProvidersNurse's Aide