Provider Demographics
NPI:1780004317
Name:JOHNSON, DONNA (PHLEBOTOMIST)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PHLEBOTOMIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10916 S SANGAMON ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-3836
Mailing Address - Country:US
Mailing Address - Phone:800-641-6130
Mailing Address - Fax:
Practice Address - Street 1:10916 S SANGAMON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-3836
Practice Address - Country:US
Practice Address - Phone:800-641-6130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-22
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILD4B3A5A9246RP1900X
ILB8G9N5W2247200000X
ILZ6D2E9R4247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other