Provider Demographics
NPI:1841578549
Name:JOHNSON, LATASHA VERONICA (TRANSPORTATION)
Entity Type:Individual
Prefix:
First Name:LATASHA
Middle Name:VERONICA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:TRANSPORTATION
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1456 PANAMA AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46241-2964
Mailing Address - Country:US
Mailing Address - Phone:317-222-6268
Mailing Address - Fax:
Practice Address - Street 1:1456 PANAMA AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46241-2964
Practice Address - Country:US
Practice Address - Phone:317-222-6268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-28
Last Update Date:2011-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN5400224531343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)