MEDICARE: ERVINA MAE JOHNSON-MAYTUBBY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1174829055
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERVINA MAE JOHNSON-MAYTUBBY

Provider Business Mailing Address
First Line	:	8828 OAKRIDGE DR
Second Line	:
City	:	MIDWEST CITY
State	:	OK
Zip	:	73110-7418
Country	:	US
Telephone Number	:	214-854-8516
Fax Number	:

Provider Business Practice Location Address
First Line	:	8828 OAKRIDGE DR
Second Line	:
City	:	MIDWEST CITY
State	:	OK
Zip	:	73110-7418
Country	:	US
Telephone Number	:	214-854-8516
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/10/2011
Last Update Date	:	07/14/2016

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