Provider Demographics
NPI:1265941512
Name:JOHNSON, NEDRA
Entity type:Individual
Prefix:MS
First Name:NEDRA
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:PO BOX 270376
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75227-0376
Mailing Address - Country:US
Mailing Address - Phone:214-280-0379
Mailing Address - Fax:
Practice Address - Street 1:5409 N JIM MILLER RD STE 211
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75227-1523
Practice Address - Country:US
Practice Address - Phone:214-280-0379
Practice Address - Fax:214-817-2571
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-28
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
No172A00000XOther Service ProvidersDriverGroup - Single Specialty
No2472R0900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherRenal DialysisGroup - Single Specialty
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No251E00000XAgenciesHome Health
No251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization
No251V00000XAgenciesVoluntary or Charitable
No253J00000XAgenciesFoster Care Agency
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No332U00000XSuppliersHome Delivered Meals
No342000000XTransportation ServicesTransportation Network Company
No347C00000XTransportation ServicesPrivate Vehicle
No372600000XNursing Service Related ProvidersAdult Companion
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty