Provider Demographics
NPI:1962107326
Name:JOHNSON, ANTOINETTE LASHETTE
Entity type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:LASHETTE
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 1:3863 CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-4009
Mailing Address - Country:US
Mailing Address - Phone:314-664-3927
Mailing Address - Fax:314-664-0556
Practice Address - Street 1:3863 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-4009
Practice Address - Country:US
Practice Address - Phone:314-664-3927
Practice Address - Fax:314-664-0556
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-04
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist