Provider Demographics
NPI:1710495445
Name:JOHNSON, ANISSA D
Entity Type:Individual
Prefix:MS
First Name:ANISSA
Middle Name:D
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 1:6216 MEADOWHAVEN LN
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89103-1124
Mailing Address - Country:US
Mailing Address - Phone:702-245-9905
Mailing Address - Fax:702-293-3664
Practice Address - Street 1:6216 MEADOWHAVEN LN
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-1124
Practice Address - Country:US
Practice Address - Phone:702-245-9905
Practice Address - Fax:702-293-3664
Is Sole Proprietor?:No
Enumeration Date:2018-01-16
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV$$$$$$$$$Medicaid