Provider Demographics
NPI:1295481497
Name:JOHNSON, ETTA JUSTEEN
Entity type:Individual
Prefix:
First Name:ETTA
Middle Name:JUSTEEN
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 1:121 SMOOT AVE APT C
Mailing Address - Street 2:
Mailing Address - City:DUNBAR
Mailing Address - State:WV
Mailing Address - Zip Code:25064-1457
Mailing Address - Country:US
Mailing Address - Phone:304-410-7368
Mailing Address - Fax:
Practice Address - Street 1:121 SMOOT AVE APT C
Practice Address - Street 2:
Practice Address - City:DUNBAR
Practice Address - State:WV
Practice Address - Zip Code:25064-1457
Practice Address - Country:US
Practice Address - Phone:304-410-7368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-25
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant