Provider Demographics
NPI:1790007458
Name:JOHNSON, TRACI L (RN, CCM)
Entity Type:Individual
Prefix:MS
First Name:TRACI
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RN, CCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 HILLBROOKE DR
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76001-7583
Mailing Address - Country:US
Mailing Address - Phone:636-375-0634
Mailing Address - Fax:
Practice Address - Street 1:805 HILLBROOKE DR
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76001-7583
Practice Address - Country:US
Practice Address - Phone:636-375-0634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-23
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX776453163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management