Provider Demographics
NPI:1922547298
Name:YVETTE M JOHNSON LLC
Entity Type:Organization
Organization Name:YVETTE M JOHNSON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL
Authorized Official - Prefix:
Authorized Official - First Name:YVETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-785-7094
Mailing Address - Street 1:1944 W 163RD ST
Mailing Address - Street 2:
Mailing Address - City:MARKHAM
Mailing Address - State:IL
Mailing Address - Zip Code:60428-5647
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1944 W 163RD ST
Practice Address - Street 2:
Practice Address - City:MARKHAM
Practice Address - State:IL
Practice Address - Zip Code:60428-5647
Practice Address - Country:US
Practice Address - Phone:708-785-7094
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-19
Last Update Date:2017-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.014010363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209.014010OtherLICENSE