Provider Demographics
NPI:1366939407
Name:JOHNSON, CHARLOTTE WINNIE
Entity type:Individual
Prefix:MS
First Name:CHARLOTTE
Middle Name:WINNIE
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 1:1811 MCDONALD ST
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79707-6716
Mailing Address - Country:US
Mailing Address - Phone:432-889-8105
Mailing Address - Fax:
Practice Address - Street 1:1811 MCDONALD ST
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79707-6716
Practice Address - Country:US
Practice Address - Phone:432-889-8105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-14
Last Update Date:2018-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX116378164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse