Provider Demographics
NPI:1710110168
Name:JOHNSON, MANITA YVETTE
Entity Type:Individual
Prefix:
First Name:MANITA
Middle Name:YVETTE
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 1:3125 EASTWAY DR
Mailing Address - Street 2:SUITE 213
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-5643
Mailing Address - Country:US
Mailing Address - Phone:704-621-2201
Mailing Address - Fax:704-900-6140
Practice Address - Street 1:3125 EASTWAY DR
Practice Address - Street 2:SUITE 213
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205-5643
Practice Address - Country:US
Practice Address - Phone:704-621-2201
Practice Address - Fax:704-900-6140
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-02
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications