Provider Demographics
NPI:1720878739
Name:JOHNSON, DOMINIQUE AMANDA
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:AMANDA
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 1:2118 S FLORENCE AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-2766
Mailing Address - Country:US
Mailing Address - Phone:314-226-7977
Mailing Address - Fax:
Practice Address - Street 1:2118 S FLORENCE AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-2766
Practice Address - Country:US
Practice Address - Phone:314-226-7977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-12
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide