MEDICARE: CHERRISH CHERRISH JOHNSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2017374	OTHER	TX	DEPARTMENT OF INSURANCE

General Provider Information

NPI Number	:	1669901906
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHERRISH CHERRISH JOHNSON

Provider Business Mailing Address
First Line	:	4312 LARKEL ST
Second Line	:
City	:	PLANO
State	:	TX
Zip	:	75093-2621
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4312 LARKEL ST
Second Line	:
City	:	PLANO
State	:	TX
Zip	:	75093-2621
Country	:	US
Telephone Number	:	573-647-1192
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/09/2017
Last Update Date	:	06/16/2018

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