MEDICARE: MS. MALLISSIE V 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	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1932402799
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MALLISSIE V JOHNSON

Provider Business Mailing Address
First Line	:	5563 LIVE OAK ST
Second Line	:	#6
City	:	HOUSTON
State	:	TX
Zip	:	77004-7556
Country	:	US
Telephone Number	:	281-682-6498
Fax Number	:

Provider Business Practice Location Address
First Line	:	12935 MAIN ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77035-5603
Country	:	US
Telephone Number	:	281-682-6498
Fax Number	:

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

Provider Enumeration Date	:	12/15/2010
Last Update Date	:	12/15/2010

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