Healthcare Provider Details

I. General information

NPI: 1659235729
Provider Name (Legal Business Name): TATIANNA JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2025
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1751 BELLAMAH AVE NW APT 2109
ALBUQUERQUE NM
87104-2226
US

IV. Provider business mailing address

1751 BELLAMAH AVE NW APT 2109
ALBUQUERQUE NM
87104-2226
US

V. Phone/Fax

Practice location:
  • Phone: 512-522-9552
  • Fax:
Mailing address:
  • Phone: 512-522-9552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156F00000X
TaxonomyTechnician/Technologist
License NumberBCB-2025-1416
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: