Provider Demographics
NPI:1770276867
Name:JOHNSON, TINA LYVETTE
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:LYVETTE
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 1:16023 BROADWATER DR
Mailing Address - Street 2:
Mailing Address - City:CROSBY
Mailing Address - State:TX
Mailing Address - Zip Code:77532-5328
Mailing Address - Country:US
Mailing Address - Phone:832-227-9787
Mailing Address - Fax:
Practice Address - Street 1:16023 BROADWATER DR
Practice Address - Street 2:
Practice Address - City:CROSBY
Practice Address - State:TX
Practice Address - Zip Code:77532-5328
Practice Address - Country:US
Practice Address - Phone:832-227-9787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-02
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physician