MEDICARE: DE VON JOHNSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	376J00000X	Homemaker

General Provider Information

NPI Number	:	1396481297
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DE VON JOHNSON

Provider Business Mailing Address
First Line	:	9125 FISH TAIL AVE UNIT 103
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89149-3168
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9125 FISH TAIL AVE UNIT 103
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89149-3168
Country	:	US
Telephone Number	:	702-955-1774
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/12/2022
Last Update Date	:	05/12/2022

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Directions to “ DE VON JOHNSON ” Practice Location

Language	Start Address	Practice Location

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