Provider Demographics
NPI:1255635470
Name:JOHNSON, MARY L (MANAGER)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MANAGER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 366
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:TX
Mailing Address - Zip Code:75653-0366
Mailing Address - Country:US
Mailing Address - Phone:903-657-3548
Mailing Address - Fax:
Practice Address - Street 1:3735 HWY 64W
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:TX
Practice Address - Zip Code:75653-0366
Practice Address - Country:US
Practice Address - Phone:903-657-3548
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-03
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX131028172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker