Healthcare Provider Details

I. General information

NPI: 1245946581
Provider Name (Legal Business Name): TIA NICOLE JOHNSON IDMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2023
Last Update Date: 01/30/2023
Certification Date: 01/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18230 E SILVER CREEK AVE RM 205
AURORA CO
80011-9501
US

IV. Provider business mailing address

9551 SADDLE SORE CIR
CASHION OK
73016-9449
US

V. Phone/Fax

Practice location:
  • Phone: 720-847-6486
  • Fax:
Mailing address:
  • Phone: 405-204-4474
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: