Provider Demographics
NPI:1932588027
Name:JOHNSON, JANISE LACHELLE
Entity type:Individual
Prefix:MS
First Name:JANISE
Middle Name:LACHELLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2474 RENOIS LN
Mailing Address - Street 2:
Mailing Address - City:CAHOKIA
Mailing Address - State:IL
Mailing Address - Zip Code:62206-3015
Mailing Address - Country:US
Mailing Address - Phone:618-799-2454
Mailing Address - Fax:
Practice Address - Street 1:2474 RENOIS LN
Practice Address - Street 2:
Practice Address - City:CAHOKIA
Practice Address - State:IL
Practice Address - Zip Code:62206-3015
Practice Address - Country:US
Practice Address - Phone:618-799-2454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-22
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043115886164W00000X
MO2013021137164W00000X
IL049.211871183700000X
MO2013012431183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No183700000XPharmacy Service ProvidersPharmacy Technician