MEDICARE: MS. ANGELINA FAWN JOHNNY

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	225400000X	Rehabilitation Practitioner
2	171W00000X	Contractor

General Provider Information

NPI Number	:	1619383387
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ANGELINA FAWN JOHNNY

Provider Business Mailing Address
First Line	:	8367 EMBRY HILLS ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89113-4602
Country	:	US
Telephone Number	:	725-260-5108
Fax Number	:

Provider Business Practice Location Address
First Line	:	6889 SOUTH EASTERN AVENUE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119
Country	:	US
Telephone Number	:	702-434-1200
Fax Number	:

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

Provider Enumeration Date	:	07/02/2014
Last Update Date	:	11/17/2022

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