Provider Demographics
NPI:1013342195
Name:JOHNS, CHARLES DAVID (RN)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:DAVID
Last Name:JOHNS
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4929 BRADEN ST
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:MI
Mailing Address - Zip Code:49056-9249
Mailing Address - Country:US
Mailing Address - Phone:269-605-9103
Mailing Address - Fax:
Practice Address - Street 1:555 RAILROAD ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:MI
Practice Address - Zip Code:49013-1464
Practice Address - Country:US
Practice Address - Phone:269-427-6171
Practice Address - Fax:866-242-4929
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-09
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO4704265201163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse