Provider Demographics
NPI:1417553215
Name:JOHNSON, CHARISMA SHAUNTAE (LVN)
Entity Type:Individual
Prefix:
First Name:CHARISMA
Middle Name:SHAUNTAE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:CA
Mailing Address - Zip Code:92251-1404
Mailing Address - Country:US
Mailing Address - Phone:424-207-7947
Mailing Address - Fax:
Practice Address - Street 1:601 W 3RD ST
Practice Address - Street 2:
Practice Address - City:IMPERIAL
Practice Address - State:CA
Practice Address - Zip Code:92251-1404
Practice Address - Country:US
Practice Address - Phone:424-207-7947
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-07
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA231556164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse