Provider Demographics
NPI:1285366500
Name:JOHNSON, TAKEIYAH ELLYSE
Entity type:Individual
Prefix:
First Name:TAKEIYAH
Middle Name:ELLYSE
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 1:9702 N SAM HOUSTON PKWY E
Mailing Address - Street 2:
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77396-4528
Mailing Address - Country:US
Mailing Address - Phone:256-655-0662
Mailing Address - Fax:
Practice Address - Street 1:9702 N SAM HOUSTON PKWY E
Practice Address - Street 2:
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77396-4528
Practice Address - Country:US
Practice Address - Phone:256-655-0662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-27
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX000000204R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204R00000XAllopathic & Osteopathic PhysiciansElectrodiagnostic Medicine