Provider Demographics
NPI:1619383387
Name:JOHNNY, ANGELINA FAWN
Entity Type:Individual
Prefix:MS
First Name:ANGELINA
Middle Name:FAWN
Last Name:JOHNNY
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 1:8367 EMBRY HILLS ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-4602
Mailing Address - Country:US
Mailing Address - Phone:725-260-5108
Mailing Address - Fax:
Practice Address - Street 1:6889 SOUTH EASTERN AVENUE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119
Practice Address - Country:US
Practice Address - Phone:702-434-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-02
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner