Provider Demographics
NPI:1093940363
Name:JOHNSON, ANDRENE RENEE
Entity Type:Individual
Prefix:MS
First Name:ANDRENE
Middle Name:RENEE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANDRENE
Other - Middle Name:RENEE
Other - Last Name:TRAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1803 W. 95TH ST.
Mailing Address - Street 2:UNIT 196
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-1103
Mailing Address - Country:US
Mailing Address - Phone:312-259-4200
Mailing Address - Fax:773-298-0673
Practice Address - Street 1:3224 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:PARK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60466
Practice Address - Country:US
Practice Address - Phone:312-259-4200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-15
Last Update Date:2009-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies