Provider Demographics
NPI:1104547538
Name:JOHNSON, CHADERICK DEMOND
Entity type:Individual
Prefix:
First Name:CHADERICK
Middle Name:DEMOND
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:747 PINEY FOREST RD
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24540-2860
Mailing Address - Country:US
Mailing Address - Phone:434-429-8848
Mailing Address - Fax:434-549-9051
Practice Address - Street 1:747 PINEY FOREST RD
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24540-2860
Practice Address - Country:US
Practice Address - Phone:434-429-8848
Practice Address - Fax:434-549-9051
Is Sole Proprietor?:No
Enumeration Date:2022-09-05
Last Update Date:2022-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA910440364SC2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SC2300XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistChronic Care