Provider Demographics
NPI:1245713460
Name:JOHNSON-VINCENT, LARETHA
Entity type:Individual
Prefix:
First Name:LARETHA
Middle Name:
Last Name:JOHNSON-VINCENT
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 1:125 N OKLAHOMA AVE
Mailing Address - Street 2:
Mailing Address - City:MANGUM
Mailing Address - State:OK
Mailing Address - Zip Code:73554-4279
Mailing Address - Country:US
Mailing Address - Phone:713-876-0839
Mailing Address - Fax:
Practice Address - Street 1:125 N OKLAHOMA AVE
Practice Address - Street 2:
Practice Address - City:MANGUM
Practice Address - State:OK
Practice Address - Zip Code:73554-4279
Practice Address - Country:US
Practice Address - Phone:713-876-0839
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-13
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor