Provider Demographics
NPI:1063585958
Name:JOHNSON, JOHNNIE FAYE (MEDICAL ASSISTANT)
Entity type:Individual
Prefix:MRS
First Name:JOHNNIE
Middle Name:FAYE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MEDICAL ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2007 MAPLELEAF DR
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62234-5224
Mailing Address - Country:US
Mailing Address - Phone:618-344-3276
Mailing Address - Fax:
Practice Address - Street 1:2007 MAPLELEAF DR
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62234-5224
Practice Address - Country:US
Practice Address - Phone:618-344-3276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL74613 16 RMA247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other