Provider Demographics
NPI:1952760860
Name:JOHNSON, VERNICE LYNN (COSMETOLOGIST)
Entity Type:Individual
Prefix:
First Name:VERNICE
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:COSMETOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4027 E 45TH ST
Mailing Address - Street 2:1658 E. 63RD STREET
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64130-2125
Mailing Address - Country:US
Mailing Address - Phone:816-361-2955
Mailing Address - Fax:
Practice Address - Street 1:4027 E 45TH ST
Practice Address - Street 2:1658 E. 63RD STREET
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64131-2125
Practice Address - Country:US
Practice Address - Phone:816-361-2955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-19
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007011655335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO335E00000XMedicare Oscar/Certification