Healthcare Provider Details

I. General information

NPI: 1578341830
Provider Name (Legal Business Name): CHINETHIA H JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2023
Last Update Date: 09/18/2023
Certification Date: 09/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6130 HUNTER AVE
CHARLOTTE NC
28262-3108
US

IV. Provider business mailing address

6130 HUNTER AVE
CHARLOTTE NC
28262-3108
US

V. Phone/Fax

Practice location:
  • Phone: 704-431-8052
  • Fax:
Mailing address:
  • Phone: 704-431-8052
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number85594
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: