Provider Demographics
NPI:1265116396
Name:JOHNSON, TERRANCE DEVOREA
Entity type:Individual
Prefix:MR
First Name:TERRANCE
Middle Name:DEVOREA
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 1:911 E MASON LN UNIT 13
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92805-6404
Mailing Address - Country:US
Mailing Address - Phone:714-386-2445
Mailing Address - Fax:
Practice Address - Street 1:911 E MASON LN UNIT 13
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-6404
Practice Address - Country:US
Practice Address - Phone:714-386-2445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-09
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD3912551172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver