Provider Demographics
NPI:1053866830
Name:JOHNSON, BRENDA DEMETRIUS (CNA)
Entity Type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:DEMETRIUS
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:DEMETRIUS
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNA
Mailing Address - Street 1:1114 S SPRINGINSGUTH RD
Mailing Address - Street 2:APT 2B
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60193-3486
Mailing Address - Country:US
Mailing Address - Phone:847-302-4541
Mailing Address - Fax:
Practice Address - Street 1:1114 S SPRINGINSGUTH RD APT 2B
Practice Address - Street 2:
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60193-3463
Practice Address - Country:US
Practice Address - Phone:847-302-4541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-22
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL390376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide