Healthcare Provider Details

I. General information

NPI: 1316589146
Provider Name (Legal Business Name): MRS. ANN FILLINGHAM JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2019
Last Update Date: 10/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N UNIVERSITY DR
FORT WORTH TX
76107-1360
US

IV. Provider business mailing address

4201 LAKE VISTA DR
BENBROOK TX
76132-2747
US

V. Phone/Fax

Practice location:
  • Phone: 817-814-2000
  • Fax:
Mailing address:
  • Phone: 254-715-2249
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number10221
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: