Healthcare Provider Details

I. General information

NPI: 1124541941
Provider Name (Legal Business Name): DEMETRIA SONJA LEAK CNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DEMETRIA SONJA JOHNSON

II. Dates (important events)

Enumeration Date: 07/24/2017
Last Update Date: 07/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1032 MCCALLIE AVE
CHATTANOOGA TN
37403-2800
US

IV. Provider business mailing address

6350 W ANDREW JOHNSON HWY DEPT 100
TALBOTT TN
37877-8605
US

V. Phone/Fax

Practice location:
  • Phone: 423-266-4588
  • Fax: 865-342-0103
Mailing address:
  • Phone: 800-355-3565
  • Fax: 423-714-2355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number69073
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: