Provider Demographics
NPI:1700242369
Name:JOHNSON, DORETTA (CNA)
Entity Type:Individual
Prefix:
First Name:DORETTA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1122 OAKLAWN AVE APT C
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28206-3157
Mailing Address - Country:US
Mailing Address - Phone:803-327-2273
Mailing Address - Fax:803-327-2275
Practice Address - Street 1:115 OAKLAND AVE STE 101C
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29730-4033
Practice Address - Country:US
Practice Address - Phone:803-327-2273
Practice Address - Fax:803-327-2275
Is Sole Proprietor?:No
Enumeration Date:2016-01-12
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant