Healthcare Provider Details

I. General information

NPI: 1518192327
Provider Name (Legal Business Name): TERRY LYNN JOHNSON IDMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2009
Last Update Date: 03/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SPANGDAHLEM AB 52 MDOS UNIT 3865
APO AE
09126
US

IV. Provider business mailing address

PSC 9 BOX 4704
APO AE
09123-0048
US

V. Phone/Fax

Practice location:
  • Phone: 00496565618373
  • Fax:
Mailing address:
  • Phone: 00496565933666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number03393628
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: