Provider Demographics
NPI:1669288890
Name:JOHNSON, ELISHA DAWNE
Entity type:Individual
Prefix:
First Name:ELISHA
Middle Name:DAWNE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELISHA
Other - Middle Name:DAWNE
Other - Last Name:MADDEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1306 WHIPPOORWILL DR
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73071-1625
Mailing Address - Country:US
Mailing Address - Phone:405-510-6412
Mailing Address - Fax:
Practice Address - Street 1:1306 WHIPPOORWILL DR
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071-1625
Practice Address - Country:US
Practice Address - Phone:405-510-6412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-03
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist