Provider Demographics
NPI:1548734718
Name:JOHNSON, TRIVY (CERTIFIED HAIR LOSS)
Entity Type:Individual
Prefix:
First Name:TRIVY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CERTIFIED HAIR LOSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 N PATTERSON AVE UNIT 562
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27102-0157
Mailing Address - Country:US
Mailing Address - Phone:336-310-4660
Mailing Address - Fax:336-310-4660
Practice Address - Street 1:8011 N POINT BLVD STE L
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-3244
Practice Address - Country:US
Practice Address - Phone:336-310-4660
Practice Address - Fax:336-310-4660
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-21
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC810801744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000000000OtherN/A