Provider Demographics
NPI:1659875151
Name:JOHNSON, JOHQUALA
Entity Type:Individual
Prefix:
First Name:JOHQUALA
Middle Name:
Last Name:JOHNSON
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 1:3450 COUNTRY CLUB DR W APT 183
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-8157
Mailing Address - Country:US
Mailing Address - Phone:469-544-7444
Mailing Address - Fax:
Practice Address - Street 1:1115 SOUTHPOINTE DR
Practice Address - Street 2:
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-4277
Practice Address - Country:US
Practice Address - Phone:469-626-7232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-20
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker