Provider Demographics
NPI:1205274743
Name:JOHNSON, CAROL
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:
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 1:1290 W HORIZON RIDGE PKWY APT 2427
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89012-5538
Mailing Address - Country:US
Mailing Address - Phone:702-824-4073
Mailing Address - Fax:
Practice Address - Street 1:5230 W PATRICK LN STE 140
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89118-5852
Practice Address - Country:US
Practice Address - Phone:702-570-5104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-06
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner