Provider Demographics
NPI:1457159394
Name:JOHNSON, TISA S
Entity type:Individual
Prefix:
First Name:TISA
Middle Name:S
Last Name:JOHNSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4850 VINEWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94531-8126
Mailing Address - Country:US
Mailing Address - Phone:925-497-2479
Mailing Address - Fax:
Practice Address - Street 1:60 GOLD CREST CT
Practice Address - Street 2:
Practice Address - City:PITTSBURG
Practice Address - State:CA
Practice Address - Zip Code:94565-6500
Practice Address - Country:US
Practice Address - Phone:925-267-2059
Practice Address - Fax:925-877-8446
Is Sole Proprietor?:No
Enumeration Date:2025-03-06
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker