Individual
MRS. DESERAE LEI JOHNSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
LMT
Contact information
Practice address
1654 W BOISE ST, KUNA, ID 83634-3137
(208) 409-0422
Mailing address
1654 W BOISE ST, KUNA, ID 83634-3137
(208) 409-0422
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
MAS-1035
ID
Other
Enumeration date
04/05/2014
Last updated
04/05/2014
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