1013224286 NPI number — MRS. MILICENT CHERISSE JOHNSON CPNP

Table of content: MRS. MILICENT CHERISSE JOHNSON CPNP (NPI 1013224286)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013224286 NPI number — MRS. MILICENT CHERISSE JOHNSON CPNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
MILICENT
Provider Middle Name:
CHERISSE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CPNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HELMS
Provider Other First Name:
MILICENT
Provider Other Middle Name:
CHERISSE
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
RN
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1013224286
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/08/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3821 OAK VALLEY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KILLEEN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76542-4532
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
254-690-7452
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2401 S 31ST ST
Provider Second Line Business Practice Location Address:
4B PEDIATRIC GASTROENTEROLOGY CLINIC
Provider Business Practice Location Address City Name:
TEMPLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76508-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-724-2708
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/08/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0200X , with the licence number:  634850 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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