Provider Demographics
NPI:1437644309
Name:JOHNSON, DESTINY JANE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:DESTINY
Middle Name:JANE
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 1:6110 SHALLOWFORD RD STE B
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-1894
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6110 SHALLOWFORD RD STE B
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-1894
Practice Address - Country:US
Practice Address - Phone:423-499-1031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-24
Last Update Date:2018-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN85506164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse