Provider Demographics
NPI:1821278490
Name:JOHNSON, DETRINETTE
Entity Type:Individual
Prefix:
First Name:DETRINETTE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DETRINETTE
Other - Middle Name:
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6645 VINEYARD DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70812-2148
Mailing Address - Country:US
Mailing Address - Phone:225-358-6823
Mailing Address - Fax:225-356-1498
Practice Address - Street 1:6645 VINEYARD DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70812-2148
Practice Address - Country:US
Practice Address - Phone:225-358-6823
Practice Address - Fax:225-356-1498
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-12
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1455890Medicaid