1235423690 NPI number — MS. JOYCELYN ANNETTE JOHNSON D.T.

Table of content: MS. JOYCELYN ANNETTE JOHNSON D.T. (NPI 1235423690)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235423690 NPI number — MS. JOYCELYN ANNETTE JOHNSON D.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
JOYCELYN
Provider Middle Name:
ANNETTE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
D.T.
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:
1235423690
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/02/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4850 S LAKE PARK AVE # 21007
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60615-2130
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4850 S LAKE PARK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60615-2130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-624-5089
Provider Business Practice Location Address Fax Number:
773-624-5089
Provider Enumeration Date:
06/02/2011

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: 222Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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