Provider Demographics
NPI:1104558899
Name:JOHNSON, NEISHA (NURSE, HEALTH CARE P)
Entity type:Individual
Prefix:
First Name:NEISHA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:NURSE, HEALTH CARE P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11132 E 84TH TER
Mailing Address - Street 2:
Mailing Address - City:RAYTOWN
Mailing Address - State:MO
Mailing Address - Zip Code:64138-3646
Mailing Address - Country:US
Mailing Address - Phone:816-602-7886
Mailing Address - Fax:
Practice Address - Street 1:11132 E 84TH TER
Practice Address - Street 2:
Practice Address - City:RAYTOWN
Practice Address - State:MO
Practice Address - Zip Code:64138-3646
Practice Address - Country:US
Practice Address - Phone:816-602-7886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-30
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care ProviderGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP203240023Medicaid