Provider Demographics
NPI:1730635897
Name:JOHNSON, ANGELA
Entity Type:Individual
Prefix:
First Name:ANGELA
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 1:1760 BARKER CYPRESS RD
Mailing Address - Street 2:823
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77084-6152
Mailing Address - Country:US
Mailing Address - Phone:757-289-9262
Mailing Address - Fax:
Practice Address - Street 1:9422 PECOS PASS CT
Practice Address - Street 2:
Practice Address - City:CYPRESS
Practice Address - State:TX
Practice Address - Zip Code:77433-3778
Practice Address - Country:US
Practice Address - Phone:855-832-6727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-29
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX40195361247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX$$$$$$$$$Medicaid