MEDICARE: EARLEANE JOHNSON QMHA

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	225400000X	Rehabilitation Practitioner

General Provider Information

NPI Number	:	1922305291
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EARLEANE JOHNSON QMHA

Provider Business Mailing Address
First Line	:	2275 RENAISSANCE DR STE D
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-6797
Country	:	US
Telephone Number	:	702-739-7716
Fax Number	:	702-597-2242

Provider Business Practice Location Address
First Line	:	2275 RENAISSANCE DR STE D
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-6797
Country	:	US
Telephone Number	:	702-739-7716
Fax Number	:	702-597-2242

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

Provider Enumeration Date	:	02/22/2011
Last Update Date	:	03/05/2015

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