Individual
KEA JOHNSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
2714 S 2ND AVE, DALLAS, TX 75210-2090
(469) 720-3797
Mailing address
PO BOX 2852, ROWLETT, TX 75030-2852
(469) 720-3797
Taxonomy
Speciality
Code
Description
License number
State
171W00000X
Contractor
Primary
45D2249010
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
45D2249010
CLIA WAIVER
TX
Enumeration date
01/25/2022
Last updated
01/25/2022
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