Provider Demographics
NPI:1124875547
Name:JOHNSON, SHERYL RAE (SOLE PROPRIETOR)
Entity type:Individual
Prefix:
First Name:SHERYL
Middle Name:RAE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:SOLE PROPRIETOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W11474 US HIGHWAY 8
Mailing Address - Street 2:
Mailing Address - City:HAWKINS
Mailing Address - State:WI
Mailing Address - Zip Code:54530-9307
Mailing Address - Country:US
Mailing Address - Phone:715-826-0329
Mailing Address - Fax:
Practice Address - Street 1:W11474 US HIGHWAY 8
Practice Address - Street 2:
Practice Address - City:HAWKINS
Practice Address - State:WI
Practice Address - Zip Code:54530-9307
Practice Address - Country:US
Practice Address - Phone:715-826-0329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-03
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI0014401310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility