Provider Demographics
NPI:1497847255
Name:JOHNSON, EBONY NICOLE (MD)
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:NICOLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27702 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-1277
Mailing Address - Country:US
Mailing Address - Phone:708-862-7674
Mailing Address - Fax:708-862-1781
Practice Address - Street 1:4742 CAL SAG RD
Practice Address - Street 2:
Practice Address - City:CRESTWOOD
Practice Address - State:IL
Practice Address - Zip Code:60418
Practice Address - Country:US
Practice Address - Phone:708-915-2727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL03612077207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine