Provider Demographics
NPI:1659619617
Name:JOHNSON-WILEY, ELLA RENE
Entity Type:Individual
Prefix:
First Name:ELLA
Middle Name:RENE
Last Name:JOHNSON-WILEY
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 1:1720 GATEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89108-2518
Mailing Address - Country:US
Mailing Address - Phone:702-647-4735
Mailing Address - Fax:
Practice Address - Street 1:1720 GATEWOOD DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89108-2518
Practice Address - Country:US
Practice Address - Phone:702-647-4735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-26
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner