Provider Demographics
NPI:1720346943
Name:JOHNSON, ANTQUALENE LAVETTE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:ANTQUALENE
Middle Name:LAVETTE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2260 GLORY LOOP
Mailing Address - Street 2:BLDG 1260
Mailing Address - City:FORT POLK
Mailing Address - State:LA
Mailing Address - Zip Code:71446
Mailing Address - Country:US
Mailing Address - Phone:337-531-4127
Mailing Address - Fax:
Practice Address - Street 1:2260 GLORY LOOP
Practice Address - Street 2:BLDG 1260
Practice Address - City:FORT POLK
Practice Address - State:LA
Practice Address - Zip Code:71446
Practice Address - Country:US
Practice Address - Phone:337-531-4127
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-25
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1103343363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical