Provider Demographics
NPI:1518508803
Name:JOHNSON, CHERYL ANN
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:ANN
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 1:830 EDGEWOOD DR.
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311
Mailing Address - Country:US
Mailing Address - Phone:920-465-9977
Mailing Address - Fax:920-544-5768
Practice Address - Street 1:830 EDGEWOOD DR.
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311
Practice Address - Country:US
Practice Address - Phone:920-465-9977
Practice Address - Fax:920-544-5768
Is Sole Proprietor?:No
Enumeration Date:2019-10-08
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
171M0000X174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator