Provider Demographics
NPI:1326859570
Name:JOHNSON, ILYASAH Q (CNA,PBT)
Entity type:Individual
Prefix:
First Name:ILYASAH
Middle Name:Q
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CNA,PBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:890 E WALNUT RD APT 38
Mailing Address - Street 2:
Mailing Address - City:VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08360-5040
Mailing Address - Country:US
Mailing Address - Phone:609-405-5974
Mailing Address - Fax:
Practice Address - Street 1:115 PHILADELPHIA AVE
Practice Address - Street 2:STE B #224
Practice Address - City:EGG HARBOR CITY
Practice Address - State:NJ
Practice Address - Zip Code:08215-1200
Practice Address - Country:US
Practice Address - Phone:856-202-6243
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-16
Last Update Date:2025-01-27
Deactivation Date:2025-01-16
Deactivation Code:
Reactivation Date:2025-01-27
Provider Licenses
StateLicense IDTaxonomies
NJNA200036261376K00000X
NJ5460-23246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomyGroup - Multi-Specialty
No376K00000XNursing Service Related ProvidersNurse's AideGroup - Multi-Specialty