Provider Demographics
NPI:1740915123
Name:JOHNSON, TIA DE'ANTRANISE
Entity type:Individual
Prefix:
First Name:TIA
Middle Name:DE'ANTRANISE
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 1:7868 FOREST LOOP
Mailing Address - Street 2:
Mailing Address - City:PINSON
Mailing Address - State:AL
Mailing Address - Zip Code:35126-4087
Mailing Address - Country:US
Mailing Address - Phone:205-356-6337
Mailing Address - Fax:
Practice Address - Street 1:7868 FOREST LOOP
Practice Address - Street 2:
Practice Address - City:PINSON
Practice Address - State:AL
Practice Address - Zip Code:35126-4087
Practice Address - Country:US
Practice Address - Phone:205-356-6337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-20
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program