MEDICARE: KEONDRA C JOHNSON

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	315P00000X	Intellectual Disabilities Intermediate Care Facility

General Provider Information

NPI Number	:	1578179750
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEONDRA C JOHNSON

Provider Business Mailing Address
First Line	:	990 HIGHWAY 287 N STE 106
Second Line	:
City	:	MANSFIELD
State	:	TX
Zip	:	76063-2643
Country	:	US
Telephone Number	:	214-695-4955
Fax Number	:

Provider Business Practice Location Address
First Line	:	2140 MEDICAL DISTRICT DR APT 2052
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75235-8097
Country	:	US
Telephone Number	:	214-695-4955
Fax Number	:

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

Provider Enumeration Date	:	09/22/2020
Last Update Date	:	09/22/2020

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Directions to “ KEONDRA C JOHNSON ” Practice Location

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