Healthcare Provider Details

I. General information

NPI: 1154269777
Provider Name (Legal Business Name): MRS. KELLY BIANCA JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2026
Last Update Date: 03/24/2026
Certification Date: 03/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9923 S CLYDE AVE
CHICAGO IL
60617-5241
US

IV. Provider business mailing address

9923 S CLYDE AVE
CHICAGO IL
60617-5241
US

V. Phone/Fax

Practice location:
  • Phone: 312-687-8497
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: