Provider Demographics
NPI:1932681616
Name:JOHNSON, EMMA MARIE
Entity Type:Individual
Prefix:MS
First Name:EMMA
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:EMMA
Other - Middle Name:MARIE
Other - Last Name:GENTRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 711
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-0711
Mailing Address - Country:US
Mailing Address - Phone:918-647-4196
Mailing Address - Fax:
Practice Address - Street 1:510 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-3536
Practice Address - Country:US
Practice Address - Phone:918-647-4196
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-30
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator