1417074121 NPI number — MISS MICHELLE GABRIELLE JOHNSON

Table of content: MISS MICHELLE GABRIELLE JOHNSON (NPI 1417074121)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417074121 NPI number — MISS MICHELLE GABRIELLE JOHNSON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
MICHELLE
Provider Middle Name:
GABRIELLE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JOHNSON
Provider Other First Name:
MICHELLE
Provider Other Middle Name:
GABRIELLE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1417074121
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9990 COUNTY FARM RD
Provider Second Line Business Mailing Address:
5
Provider Business Mailing Address City Name:
RIVERSIDE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92503-3542
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-358-4840
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9990 COUNTY FARM RD
Provider Second Line Business Practice Location Address:
5
Provider Business Practice Location Address City Name:
RIVERSIDE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92503-3542
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-358-4840
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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