Provider Demographics
NPI:1679911887
Name:JOHNSON, KENICHA MONTA (CNA)
Entity type:Individual
Prefix:
First Name:KENICHA
Middle Name:MONTA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:423 N HINDS ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38701-2929
Mailing Address - Country:US
Mailing Address - Phone:662-537-8547
Mailing Address - Fax:
Practice Address - Street 1:423 N HINDS ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38701-2929
Practice Address - Country:US
Practice Address - Phone:662-537-8547
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-10
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSA059764374U00000X, 376K00000X
376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No374U00000XNursing Service Related ProvidersHome Health Aide
No376K00000XNursing Service Related ProvidersNurse's Aide