Healthcare Provider Details

I. General information

NPI: 1225494271
Provider Name (Legal Business Name): MR. JOHNNY ANTANIO HANKSTON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2016
Last Update Date: 03/18/2024
Certification Date: 03/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2480 S MAIN ST
SOUTH SALT LAKE UT
84115-3058
US

IV. Provider business mailing address

2480 S MAIN ST
SOUTH SALT LAKE UT
84115-3058
US

V. Phone/Fax

Practice location:
  • Phone: 702-888-0263
  • Fax:
Mailing address:
  • Phone: 702-888-0263
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: