Provider Demographics
NPI:1013224286
Name:JOHNSON, MILICENT CHERISSE (CPNP)
Entity Type:Individual
Prefix:MRS
First Name:MILICENT
Middle Name:CHERISSE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:MRS
Other - First Name:MILICENT
Other - Middle Name:CHERISSE
Other - Last Name:HELMS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:3821 OAK VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76542-4532
Mailing Address - Country:US
Mailing Address - Phone:254-690-7452
Mailing Address - Fax:
Practice Address - Street 1:2401 S 31ST ST
Practice Address - Street 2:4B PEDIATRIC GASTROENTEROLOGY CLINIC
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76508-0001
Practice Address - Country:US
Practice Address - Phone:254-724-2708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-08
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX634850363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics