Healthcare Provider Details

I. General information

NPI: 1992101893
Provider Name (Legal Business Name): MR. ANTHONY EARL JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: ANTHONY EARL JOHNSON OWNER

II. Dates (important events)

Enumeration Date: 11/05/2014
Last Update Date: 11/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 N GREENWOOD AVE SUITE B
TULSA OK
74120-1444
US

IV. Provider business mailing address

121 N GREENWOOD AVE SUITE B
TULSA OK
74120-1444
US

V. Phone/Fax

Practice location:
  • Phone: 918-425-0221
  • Fax: 918-425-0222
Mailing address:
  • Phone: 918-425-0221
  • Fax: 918-425-0222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License NumberR 0075294
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number37V257521203
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: