Provider Demographics
NPI:1053941419
Name:JOHNSON, CALESHA EVONNE
Entity type:Individual
Prefix:
First Name:CALESHA
Middle Name:EVONNE
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 1:920 MALIBU SANDS AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89086-1325
Mailing Address - Country:US
Mailing Address - Phone:702-287-9525
Mailing Address - Fax:
Practice Address - Street 1:920 MALIBU SANDS AVE
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89086-1325
Practice Address - Country:US
Practice Address - Phone:702-287-9525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-24
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program