Provider Demographics
NPI:1659758100
Name:JOHNSON, TINEKA (ND)
Entity Type:Individual
Prefix:DR
First Name:TINEKA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 WEST ST
Mailing Address - Street 2:SUITE 11C
Mailing Address - City:SEYMOUR
Mailing Address - State:CT
Mailing Address - Zip Code:06483-2644
Mailing Address - Country:US
Mailing Address - Phone:203-804-8729
Mailing Address - Fax:203-702-5110
Practice Address - Street 1:133 WEST ST
Practice Address - Street 2:SUITE 11C
Practice Address - City:SEYMOUR
Practice Address - State:CT
Practice Address - Zip Code:06483-2644
Practice Address - Country:US
Practice Address - Phone:203-804-8729
Practice Address - Fax:203-702-5110
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-05
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT539175F00000X, 171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA269094OtherAPIC