Provider Demographics
NPI:1730562232
Name:JOHNSON, DELORIS
Entity type:Individual
Prefix:
First Name:DELORIS
Middle Name:
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 1:1221 LOCUST ST STE 417
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63103-2364
Mailing Address - Country:US
Mailing Address - Phone:314-932-4530
Mailing Address - Fax:314-932-4532
Practice Address - Street 1:1221 LOCUST ST STE 417
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63103-2364
Practice Address - Country:US
Practice Address - Phone:314-932-4530
Practice Address - Fax:314-932-4532
Is Sole Proprietor?:No
Enumeration Date:2015-07-01
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide