1023519667 NPI number — CHRYIL JOHNSON

Table of content: CHRYIL JOHNSON (NPI 1023519667)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023519667 NPI number — CHRYIL JOHNSON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
CHRYIL
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023519667
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/27/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
208 ICHABOD LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MCDONOUGH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30252-4965
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-314-6026
Provider Business Mailing Address Fax Number:
678-829-3329

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
208 ICHABOD LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MCDONOUGH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30252-4965
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-314-6026
Provider Business Practice Location Address Fax Number:
678-829-3329
Provider Enumeration Date:
02/27/2018

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: 376K00000X , with the licence number:  CN0030044467 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 822957221 . This is a "BUSINESS" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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