Healthcare Provider Details

I. General information

NPI: 1962107326
Provider Name (Legal Business Name): ANTOINETTE LASHETTE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2023
Last Update Date: 04/04/2023
Certification Date: 04/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3863 CLEVELAND AVE
SAINT LOUIS MO
63110-4009
US

IV. Provider business mailing address

3863 CLEVELAND AVE
SAINT LOUIS MO
63110-4009
US

V. Phone/Fax

Practice location:
  • Phone: 314-664-3927
  • Fax: 314-664-0556
Mailing address:
  • Phone: 314-664-3927
  • Fax: 314-664-0556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: