Healthcare Provider Details

I. General information

NPI: 1790007458
Provider Name (Legal Business Name): TRACI L JOHNSON RN, CCM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2010
Last Update Date: 02/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 HILLBROOKE DR
ARLINGTON TX
76001-7583
US

IV. Provider business mailing address

805 HILLBROOKE DR
ARLINGTON TX
76001-7583
US

V. Phone/Fax

Practice location:
  • Phone: 636-375-0634
  • Fax:
Mailing address:
  • Phone: 636-375-0634
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number776453
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: