1912103920 NPI number — NIKKITA CHENNILLE JOHNSON-NEEALY LPN

Table of content: NIKKITA CHENNILLE JOHNSON-NEEALY LPN (NPI 1912103920)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912103920 NPI number — NIKKITA CHENNILLE JOHNSON-NEEALY LPN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON-NEEALY
Provider First Name:
NIKKITA
Provider Middle Name:
CHENNILLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPN
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:
1912103920
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:
1458 W 123RD ST
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:
60643-5768
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-454-8514
Provider Business Mailing Address Fax Number:
708-598-3796

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1109 E 156TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOLTON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60419-2777
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-454-8514
Provider Business Practice Location Address Fax Number:
708-841-2070
Provider Enumeration Date:
06/26/2007

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: 164W00000X , with the licence number:  043.087417 , 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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