Provider Demographics
NPI:1568181287
Name:JOHNSON, BRYANNA JOSCLYNE
Entity Type:Individual
Prefix:
First Name:BRYANNA
Middle Name:JOSCLYNE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:BRYANNA
Other - Middle Name:JOSCLYNE
Other - Last Name:TUCKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1750 KAREN AVE APT 63
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89169-8710
Mailing Address - Country:US
Mailing Address - Phone:702-960-5430
Mailing Address - Fax:
Practice Address - Street 1:1771 E FLAMINGO RD STE 220A
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-0850
Practice Address - Country:US
Practice Address - Phone:702-560-2192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-25
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV106S00000X106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician