Healthcare Provider Details

I. General information

NPI: 1922813401
Provider Name (Legal Business Name): EBONY TALISE JOHNSON BSN-RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/11/2025
Last Update Date: 02/11/2025
Certification Date: 02/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1216 WEST 97TH PLACE
CHICAGO IL
60643
US

IV. Provider business mailing address

1216 W 97TH PL
CHICAGO IL
60643-1420
US

V. Phone/Fax

Practice location:
  • Phone: 708-543-0632
  • Fax:
Mailing address:
  • Phone: 708-543-0632
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number041418831
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code251F00000X
TaxonomyHome Infusion Agency
License Number28293616A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number041418831
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code251F00000X
TaxonomyHome Infusion Agency
License Number041418831
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code163WC1600X
TaxonomyContinuing Education/Staff Development Registered Nurse
License Number041418831
License Number StateIL
# 6
Primary TaxonomyN
Taxonomy Code163WI0500X
TaxonomyInfusion Therapy Registered Nurse
License Number28293616A
License Number StateIN
# 7
Primary TaxonomyN
Taxonomy Code163WI0500X
TaxonomyInfusion Therapy Registered Nurse
License Number041418831
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: