Provider Demographics
NPI:1881038313
Name:STALLION, JOHNNY
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:
Last Name:STALLION
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5055 W HACIENDA AVE
Mailing Address - Street 2:APT. 2069
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89118-0305
Mailing Address - Country:US
Mailing Address - Phone:757-724-8679
Mailing Address - Fax:
Practice Address - Street 1:5055 W HACIENDA AVE
Practice Address - Street 2:APT. 2069
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89118-0305
Practice Address - Country:US
Practice Address - Phone:757-724-8679
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-26
Last Update Date:2013-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner