Provider Demographics
NPI:1184292658
Name:JOHNSON-DODGE, TYNEIKA JOVAN (LVN)
Entity type:Individual
Prefix:
First Name:TYNEIKA
Middle Name:JOVAN
Last Name:JOHNSON-DODGE
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:928 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-5514
Mailing Address - Country:US
Mailing Address - Phone:619-977-3716
Mailing Address - Fax:619-481-3075
Practice Address - Street 1:928 BROADWAY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-5514
Practice Address - Country:US
Practice Address - Phone:619-977-3716
Practice Address - Fax:619-481-3075
Is Sole Proprietor?:No
Enumeration Date:2021-06-11
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA234008164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse