Provider Demographics
NPI:1437880705
Name:JOHNSON, REGINA
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:907 S FLOAT AVE
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-5830
Mailing Address - Country:US
Mailing Address - Phone:815-701-2934
Mailing Address - Fax:
Practice Address - Street 1:907 S FLOAT AVE
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-5830
Practice Address - Country:US
Practice Address - Phone:815-701-2934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-18
Last Update Date:2022-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide