Provider Demographics
NPI:1790144038
Name:JOHNSON-BURL, TALAWANGA
Entity Type:Individual
Prefix:DR
First Name:TALAWANGA
Middle Name:
Last Name:JOHNSON-BURL
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 1:5551 CORPORATE BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-2567
Mailing Address - Country:US
Mailing Address - Phone:225-924-1930
Mailing Address - Fax:225-924-2620
Practice Address - Street 1:5551 CORPORATE BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-2567
Practice Address - Country:US
Practice Address - Phone:225-924-1930
Practice Address - Fax:225-924-2620
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-15
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA17027183500000X
VA0202214433183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0202214433OtherVIRGINIA BOARD OF PHARMACY
LA17027OtherLOUISIANA BOARD OF PHARMACY