Provider Demographics
NPI:1699123679
Name:JOHNSON, CHERYL (LPN)
Entity type:Individual
Prefix:
First Name:CHERYL
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3830 E LAKEWOOD PKWY E APT 2052
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-0305
Mailing Address - Country:US
Mailing Address - Phone:480-278-2083
Mailing Address - Fax:
Practice Address - Street 1:10251 N 35TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85051-1305
Practice Address - Country:US
Practice Address - Phone:602-995-7366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-31
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP036784164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse