Basic Information
| Provider Information | |||||||||
| NPI: | 1952769275 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | BETHANY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LPN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHEPARD | ||||||||
| OtherFirstName: | BETHANY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LPN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 103 COMMERCE ST | ||||||||
| Address2: | |||||||||
| City: | CARMI | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628212223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183845686 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4241 HIGHWAY 14 W | ||||||||
| Address2: | |||||||||
| City: | CHRISTOPHER | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628221037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6187242401 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2016 | ||||||||
| LastUpdateDate: | 02/01/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | 043108877 | IL | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.