Provider Demographics
NPI:1578211462
Name:JOHNSON, KENYA BIANCA
Entity Type:Individual
Prefix:
First Name:KENYA
Middle Name:BIANCA
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 1:6450 W TOUHY AVE STE 212
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:IL
Mailing Address - Zip Code:60714-4512
Mailing Address - Country:US
Mailing Address - Phone:773-293-4710
Mailing Address - Fax:
Practice Address - Street 1:6450 W TOUHY AVE STE 212
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:IL
Practice Address - Zip Code:60714-4512
Practice Address - Country:US
Practice Address - Phone:773-293-4710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-10
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051300791183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist