Provider Demographics
NPI:1245946581
Name:JOHNSON, TIA NICOLE (IDMT)
Entity type:Individual
Prefix:
First Name:TIA
Middle Name:NICOLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9551 SADDLE SORE CIR
Mailing Address - Street 2:
Mailing Address - City:CASHION
Mailing Address - State:OK
Mailing Address - Zip Code:73016-9449
Mailing Address - Country:US
Mailing Address - Phone:405-204-4474
Mailing Address - Fax:
Practice Address - Street 1:18230 E SILVER CREEK AVE RM 205
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80011-9501
Practice Address - Country:US
Practice Address - Phone:720-847-6486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-30
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians