Provider Demographics
NPI:1053884098
Name:JOHNSON, ESTELLA M
Entity type:Individual
Prefix:
First Name:ESTELLA
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 COMANCHE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE KIOWA
Mailing Address - State:TX
Mailing Address - Zip Code:76240-9122
Mailing Address - Country:US
Mailing Address - Phone:940-634-1177
Mailing Address - Fax:
Practice Address - Street 1:117 COMANCHE DR
Practice Address - Street 2:
Practice Address - City:LAKE KIOWA
Practice Address - State:TX
Practice Address - Zip Code:76240-9122
Practice Address - Country:US
Practice Address - Phone:940-634-1177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-02
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX719783163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse