Provider Demographics
NPI:1699117341
Name:JOHNSON, JOHNNY SUMU
Entity type:Individual
Prefix:
First Name:JOHNNY
Middle Name:SUMU
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 1:806 WHITE FIELDS WAY
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76002-3057
Mailing Address - Country:US
Mailing Address - Phone:319-936-1773
Mailing Address - Fax:
Practice Address - Street 1:806 WHITE FIELDS WAY
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76002-3057
Practice Address - Country:US
Practice Address - Phone:319-936-1773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-23
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health