Provider Demographics
NPI:1841767878
Name:JOHNSON, FANTASIA NICOLE
Entity Type:Individual
Prefix:MISS
First Name:FANTASIA
Middle Name:NICOLE
Last Name:JOHNSON
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 1:4845 MARY KATE DR # A
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95841-2532
Mailing Address - Country:US
Mailing Address - Phone:916-912-6808
Mailing Address - Fax:
Practice Address - Street 1:6400 TUPELO DR # A
Practice Address - Street 2:
Practice Address - City:CITRUS HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:95621-1741
Practice Address - Country:US
Practice Address - Phone:916-912-6808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-29
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician