Healthcare Provider Details

I. General information

NPI: 1770276867
Provider Name (Legal Business Name): TINA LYVETTE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2023
Last Update Date: 06/02/2023
Certification Date: 06/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16023 BROADWATER DR
CROSBY TX
77532-5328
US

IV. Provider business mailing address

16023 BROADWATER DR
CROSBY TX
77532-5328
US

V. Phone/Fax

Practice location:
  • Phone: 832-227-9787
  • Fax:
Mailing address:
  • Phone: 832-227-9787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247ZC0005X
TaxonomyClinical Laboratory Director (Non-physician)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: