Provider Demographics
NPI:1336668805
Name:JOHNSON, DESHA RENEE (PRSS)
Entity type:Individual
Prefix:
First Name:DESHA
Middle Name:RENEE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PRSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6333 E SKELLY DR
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-6106
Mailing Address - Country:US
Mailing Address - Phone:918-565-4093
Mailing Address - Fax:
Practice Address - Street 1:401 E BROADWAY CT STE E
Practice Address - Street 2:
Practice Address - City:SAND SPRINGS
Practice Address - State:OK
Practice Address - Zip Code:74063-7931
Practice Address - Country:US
Practice Address - Phone:918-245-5565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-15
Last Update Date:2025-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist