Provider Demographics
NPI:1740011618
Name:JOHNSON SELLERS, LATOYA LYNNETTE (RN)
Entity type:Individual
Prefix:
First Name:LATOYA
Middle Name:LYNNETTE
Last Name:JOHNSON SELLERS
Suffix:
Gender:F
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:PO BOX 918
Mailing Address - Street 2:
Mailing Address - City:BENNETTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29512-0918
Mailing Address - Country:US
Mailing Address - Phone:843-544-4060
Mailing Address - Fax:843-454-0635
Practice Address - Street 1:1324 COMMERCE DRIVE
Practice Address - Street 2:
Practice Address - City:DILLON
Practice Address - State:SC
Practice Address - Zip Code:29536
Practice Address - Country:US
Practice Address - Phone:843-774-3351
Practice Address - Fax:843-774-2622
Is Sole Proprietor?:No
Enumeration Date:2024-08-12
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC262674163W00000X, 163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC405127Medicaid