Provider Demographics
NPI:1306526686
Name:JOHNSON, DEWAYNE JERRELL
Entity type:Individual
Prefix:MS
First Name:DEWAYNE
Middle Name:JERRELL
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1640 EMERALD CREEK DR
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63031-2046
Mailing Address - Country:US
Mailing Address - Phone:314-283-2067
Mailing Address - Fax:
Practice Address - Street 1:1640 EMERALD CREEK DR
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-2046
Practice Address - Country:US
Practice Address - Phone:314-283-2067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-20
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant