Provider Demographics
NPI:1902639057
Name:JOHNSON, DEONTE JOVAN
Entity type:Individual
Prefix:
First Name:DEONTE
Middle Name:JOVAN
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 1:3630 MOORES TRAIL RD APT 106
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43228-4346
Mailing Address - Country:US
Mailing Address - Phone:614-446-1051
Mailing Address - Fax:
Practice Address - Street 1:3630 MOORES TRAIL RD APT 106
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43228-4346
Practice Address - Country:US
Practice Address - Phone:614-446-1051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-23
Last Update Date:2024-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSW632987374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty