Provider Demographics
NPI:1609569946
Name:JOHNSON, TATIYANA SHAUNTIA RENAY
Entity Type:Individual
Prefix:
First Name:TATIYANA
Middle Name:SHAUNTIA RENAY
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 1:560 ARNOLD AVE
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44903-2148
Mailing Address - Country:US
Mailing Address - Phone:330-275-6594
Mailing Address - Fax:
Practice Address - Street 1:1095 HARCOURT RD
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050-4476
Practice Address - Country:US
Practice Address - Phone:740-848-1010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-01
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist