Provider Demographics
NPI:1871719260
Name:JOHNSON, TRINA L
Entity type:Individual
Prefix:
First Name:TRINA
Middle Name:L
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 1:1005 BERT KOUNS INDUSTRIAL LOOP
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-3411
Mailing Address - Country:US
Mailing Address - Phone:318-469-9022
Mailing Address - Fax:
Practice Address - Street 1:1005 BERT KOUNS INDUSTRIAL LOOP
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-3411
Practice Address - Country:US
Practice Address - Phone:318-469-9022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAOTAZ20332174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist