Provider Demographics
NPI:1891360863
Name:JOHNSON, DYTANYON HOWARD
Entity Type:Individual
Prefix:
First Name:DYTANYON
Middle Name:HOWARD
Last Name:JOHNSON
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 1:1450 LANGHORNE RD
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24503-2516
Mailing Address - Country:US
Mailing Address - Phone:540-642-7054
Mailing Address - Fax:434-818-0869
Practice Address - Street 1:1450 LANGHORNE RD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24503-2516
Practice Address - Country:US
Practice Address - Phone:540-642-7054
Practice Address - Fax:434-818-0869
Is Sole Proprietor?:No
Enumeration Date:2021-05-23
Last Update Date:2021-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT67311448172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver