Healthcare Provider Details

I. General information

NPI: 1386914646
Provider Name (Legal Business Name): DEBRA LEE JOHNSON CM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2012
Last Update Date: 01/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17091 SOUTH MUSKOGEE AVENUE CHEROKEE NATION
TAHLEQUAH OK
74465-0948
US

IV. Provider business mailing address

PO BOX 948
TAHLEQUAH OK
74465-0948
US

V. Phone/Fax

Practice location:
  • Phone: 918-453-5502
  • Fax: 918-458-0499
Mailing address:
  • Phone: 918-453-5502
  • Fax: 918-458-0499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number9059
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: