Provider Demographics
NPI:1922813401
Name:JOHNSON, EBONY TALISE (BSN-RN)
Entity type:Individual
Prefix:MRS
First Name:EBONY
Middle Name:TALISE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:BSN-RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1216 W 97TH PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-1420
Mailing Address - Country:US
Mailing Address - Phone:708-543-0632
Mailing Address - Fax:
Practice Address - Street 1:1216 WEST 97TH PLACE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643
Practice Address - Country:US
Practice Address - Phone:708-543-0632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-11
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041418831163WS0200X, 261QI0500X, 251F00000X, 163WC1600X, 163WI0500X
IN28293616A251F00000X, 163WI0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251F00000XAgenciesHome Infusion
No163WS0200XNursing Service ProvidersRegistered NurseSchool
No261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
No163WC1600XNursing Service ProvidersRegistered NurseContinuing Education/Staff Development
No163WI0500XNursing Service ProvidersRegistered NurseInfusion Therapy