Provider Demographics
NPI:1154816874
Name:JOHNSON, TANYENA
Entity type:Individual
Prefix:
First Name:TANYENA
Middle Name:
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 1:3920 W ANN RD STE 100
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89031-3840
Mailing Address - Country:US
Mailing Address - Phone:702-550-6700
Mailing Address - Fax:702-550-4872
Practice Address - Street 1:9128 BLACK ELK AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89143-1184
Practice Address - Country:US
Practice Address - Phone:702-994-8009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-25
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner