Provider Demographics
NPI:1164765335
Name:JOHNSON, CHAVON EBONY (LPN)
Entity Type:Individual
Prefix:MS
First Name:CHAVON
Middle Name:EBONY
Last Name:JOHNSON
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 1:5422 N 92ND ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53225-3417
Mailing Address - Country:US
Mailing Address - Phone:414-779-9728
Mailing Address - Fax:
Practice Address - Street 1:5422 N 92ND ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53225-3417
Practice Address - Country:US
Practice Address - Phone:414-779-9728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-05
Last Update Date:2013-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI309-064-31164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIBLUE0183Medicare PIN