Healthcare Provider Details

I. General information

NPI: 1457125627
Provider Name (Legal Business Name): TYRESHA DANE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2023
Last Update Date: 11/08/2023
Certification Date: 11/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5614 N FRESNO ST STE 111
FRESNO CA
93710-6034
US

IV. Provider business mailing address

5614 N FRESNO ST STE 111
FRESNO CA
93710-6034
US

V. Phone/Fax

Practice location:
  • Phone: 832-836-6326
  • Fax:
Mailing address:
  • Phone: 559-578-0306
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: