Provider Demographics
NPI:1912103920
Name:JOHNSON-NEEALY, NIKKITA CHENNILLE (LPN)
Entity type:Individual
Prefix:
First Name:NIKKITA
Middle Name:CHENNILLE
Last Name:JOHNSON-NEEALY
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 1:1458 W 123RD ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-5768
Mailing Address - Country:US
Mailing Address - Phone:773-454-8514
Mailing Address - Fax:708-598-3796
Practice Address - Street 1:1109 E 156TH ST
Practice Address - Street 2:
Practice Address - City:DOLTON
Practice Address - State:IL
Practice Address - Zip Code:60419-2777
Practice Address - Country:US
Practice Address - Phone:773-454-8514
Practice Address - Fax:708-841-2070
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043.087417164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse