Provider Demographics
NPI:1639655020
Name:JOHNSON, DAMANI KOBIE (RN)
Entity Type:Individual
Prefix:MR
First Name:DAMANI
Middle Name:KOBIE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1068 CRESTHAVEN RD STE 150
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-3859
Mailing Address - Country:US
Mailing Address - Phone:901-412-4706
Mailing Address - Fax:
Practice Address - Street 1:1068 CRESTHAVEN RD STE 150
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-3859
Practice Address - Country:US
Practice Address - Phone:901-412-4706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-18
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000172873163W00000X
TN0000024814367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse