Provider Demographics
NPI:1629579842
Name:JOHNSON, SUSAN RAYE (LVN)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:RAYE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:RAYE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LVN
Mailing Address - Street 1:303 W MARTIN AVE
Mailing Address - Street 2:
Mailing Address - City:COMANCHE
Mailing Address - State:TX
Mailing Address - Zip Code:76442-1661
Mailing Address - Country:US
Mailing Address - Phone:325-330-1206
Mailing Address - Fax:
Practice Address - Street 1:303 W MARTIN AVE
Practice Address - Street 2:
Practice Address - City:COMANCHE
Practice Address - State:TX
Practice Address - Zip Code:76442-1661
Practice Address - Country:US
Practice Address - Phone:325-330-1206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-22
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX179132164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse