Provider Demographics
NPI:1619625985
Name:HERRON, JOHNNIE SUE
Entity Type:Individual
Prefix:
First Name:JOHNNIE
Middle Name:SUE
Last Name:HERRON
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 1:96 STATE ST
Mailing Address - Street 2:
Mailing Address - City:ELKINS
Mailing Address - State:WV
Mailing Address - Zip Code:26241-3639
Mailing Address - Country:US
Mailing Address - Phone:304-704-2767
Mailing Address - Fax:
Practice Address - Street 1:1408 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:ELKINS
Practice Address - State:WV
Practice Address - Zip Code:26241-3325
Practice Address - Country:US
Practice Address - Phone:304-636-4390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-15
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant