Provider Demographics
NPI:1700635794
Name:JOHNSON, CHARISSE
Entity type:Individual
Prefix:MS
First Name:CHARISSE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:358 BRISTOL ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14206-2002
Mailing Address - Country:US
Mailing Address - Phone:716-705-1554
Mailing Address - Fax:
Practice Address - Street 1:358 BRISTOL ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14206-2002
Practice Address - Country:US
Practice Address - Phone:716-705-1554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-14
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY01HHVL3146D00000X
NY343564670514E390200000X, 376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program