MEDICARE: STARLYNNE A 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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1699347062
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STARLYNNE A JOHNSON

Provider Business Mailing Address
First Line	:	2291 W MARCH LN STE C101
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95207-6669
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6232 N PERSHING AVE APT 82
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95207-4136
Country	:	US
Telephone Number	:	209-430-1763
Fax Number	:

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

Provider Enumeration Date	:	07/14/2021
Last Update Date	:	07/14/2021

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