Provider Demographics
NPI:1952769275
Name:JOHNSON, BETHANY (LPN)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:BETHANY
Other - Middle Name:
Other - Last Name:SHEPARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:103 COMMERCE ST
Mailing Address - Street 2:
Mailing Address - City:CARMI
Mailing Address - State:IL
Mailing Address - Zip Code:62821-2223
Mailing Address - Country:US
Mailing Address - Phone:618-384-5686
Mailing Address - Fax:
Practice Address - Street 1:4241 HIGHWAY 14 W
Practice Address - Street 2:
Practice Address - City:CHRISTOPHER
Practice Address - State:IL
Practice Address - Zip Code:62822-1037
Practice Address - Country:US
Practice Address - Phone:618-724-2401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-01
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043108877164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse