Provider Demographics
NPI:1528635596
Name:JOHNSON, DOMINIQUE
Entity type:Individual
Prefix:MS
First Name:DOMINIQUE
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:PO BOX 2522
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77588-2522
Mailing Address - Country:US
Mailing Address - Phone:770-756-0125
Mailing Address - Fax:
Practice Address - Street 1:2525 BARRY ROSE RD APT 801
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77581-4593
Practice Address - Country:US
Practice Address - Phone:770-756-0125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-08
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347E00000XTransportation ServicesTransportation Broker