Provider Demographics
NPI:1376051953
Name:JOHNSON, CHERYL ANN (RN)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 PEACH BLOSSOM RD S
Mailing Address - Street 2:
Mailing Address - City:HILTON
Mailing Address - State:NY
Mailing Address - Zip Code:14468-1017
Mailing Address - Country:US
Mailing Address - Phone:585-366-7125
Mailing Address - Fax:
Practice Address - Street 1:9 PEACH BLOSSOM RD S
Practice Address - Street 2:
Practice Address - City:HILTON
Practice Address - State:NY
Practice Address - Zip Code:14468-1017
Practice Address - Country:US
Practice Address - Phone:585-366-7125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-17
Last Update Date:2018-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY471570-1163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0200XNursing Service ProvidersRegistered NursePediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY471570-1Medicaid