Provider Demographics
NPI:1063744571
Name:JOHNSON, CHARLES MILLER JR (LVN)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:MILLER
Last Name:JOHNSON
Suffix:JR
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 ROBINSON AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-4473
Mailing Address - Country:US
Mailing Address - Phone:619-581-4410
Mailing Address - Fax:
Practice Address - Street 1:1020 ROBINSON AVE APT 2
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-4473
Practice Address - Country:US
Practice Address - Phone:619-581-4410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-08
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY300231164W00000X
CAVN251826164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No164X00000XNursing Service ProvidersLicensed Vocational Nurse