1063585958 NPI number — MRS. JOHNNIE FAYE JOHNSON MEDICAL ASSISTANT

Table of content: MRS. JOHNNIE FAYE JOHNSON MEDICAL ASSISTANT (NPI 1063585958)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063585958 NPI number — MRS. JOHNNIE FAYE JOHNSON MEDICAL ASSISTANT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
JOHNNIE
Provider Middle Name:
FAYE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MEDICAL ASSISTANT
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:
1063585958
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2007 MAPLELEAF DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLLINSVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62234-5224
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-344-3276
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2007 MAPLELEAF DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLLINSVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62234-5224
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-344-3276
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/16/2006

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: 247200000X , with the licence number:  74613 16 RMA , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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