Provider Demographics
NPI:1245491422
Name:JOHNSON, FANNIE SHARIEE (MEDICAL ASISSITANT)
Entity type:Individual
Prefix:
First Name:FANNIE
Middle Name:SHARIEE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MEDICAL ASISSITANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19549 RANDOLPH PL
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80249-8609
Mailing Address - Country:US
Mailing Address - Phone:720-209-8897
Mailing Address - Fax:
Practice Address - Street 1:19549 RANDOLPH PL
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80249-8609
Practice Address - Country:US
Practice Address - Phone:720-209-8897
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-20
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
CO0021128101YA0400X
CO0335945164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No172V00000XOther Service ProvidersCommunity Health Worker
No164W00000XNursing Service ProvidersLicensed Practical Nurse