Provider Demographics
NPI:1780209387
Name:JOHNSON, ALYSHA (COSMETOLOGIST)
Entity Type:Individual
Prefix:
First Name:ALYSHA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:COSMETOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 BITTERCRESS DR
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72117-9756
Mailing Address - Country:US
Mailing Address - Phone:501-563-7392
Mailing Address - Fax:
Practice Address - Street 1:4618 JFK BLVD
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72116-7311
Practice Address - Country:US
Practice Address - Phone:501-563-7392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-10
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR29141174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist