Provider Demographics
NPI:1194704874
Name:JOHNSON, KISHA D (MD, CGC)
Entity type:Individual
Prefix:MS
First Name:KISHA
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD, CGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3802 W CONGRESS PKWY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60624-3101
Mailing Address - Country:US
Mailing Address - Phone:410-908-0683
Mailing Address - Fax:312-942-2857
Practice Address - Street 1:1750 W HARRISON ST
Practice Address - Street 2:1507 JELKE
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3825
Practice Address - Country:US
Practice Address - Phone:312-942-6298
Practice Address - Fax:312-942-2857
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS