Healthcare Provider Details

I. General information

NPI: 1376231050
Provider Name (Legal Business Name): TIFFANY NICOLE LYNNE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2023
Last Update Date: 05/01/2023
Certification Date: 04/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1235 E ST
FRESNO CA
93706-2024
US

IV. Provider business mailing address

1235 E ST
FRESNO CA
93706-2024
US

V. Phone/Fax

Practice location:
  • Phone: 559-268-6261
  • Fax: 559-268-7518
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number722614
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: