Provider Demographics
NPI:1952964504
Name:JOHNSON, TANISHA (RN)
Entity Type:Individual
Prefix:
First Name:TANISHA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:TANISHA
Other - Middle Name:
Other - Last Name:HICKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:198 KIELA PL UNIT 202
Mailing Address - Street 2:
Mailing Address - City:WAHIAWA
Mailing Address - State:HI
Mailing Address - Zip Code:96786-3341
Mailing Address - Country:US
Mailing Address - Phone:601-942-6882
Mailing Address - Fax:
Practice Address - Street 1:94-450 MOKUOLA ST STE 100
Practice Address - Street 2:
Practice Address - City:WAIPAHU
Practice Address - State:HI
Practice Address - Zip Code:96797-3388
Practice Address - Country:US
Practice Address - Phone:808-944-2882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-18
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI88247163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse