Provider Demographics
NPI:1649068776
Name:JOHNSON, CHARLETTE
Entity type:Individual
Prefix:
First Name:CHARLETTE
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 1:6650 W STATE ST # 230
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53213-2827
Mailing Address - Country:US
Mailing Address - Phone:414-467-8212
Mailing Address - Fax:
Practice Address - Street 1:11607 W BLUEMOUND RD STE 101
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-3960
Practice Address - Country:US
Practice Address - Phone:414-775-6257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-29
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty