Provider Demographics
NPI:1821856097
Name:JOHNSTON, WILLOW
Entity Type:Individual
Prefix:
First Name:WILLOW
Middle Name:
Last Name:JOHNSTON
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 1:55719 S 540 RD
Mailing Address - Street 2:
Mailing Address - City:ROSE
Mailing Address - State:OK
Mailing Address - Zip Code:74364
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:109 N FAIRLAND ST
Practice Address - Street 2:
Practice Address - City:PRYOR
Practice Address - State:OK
Practice Address - Zip Code:74361-4205
Practice Address - Country:US
Practice Address - Phone:479-220-5002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-11
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist