Provider Demographics
NPI:1871059089
Name:BROWN JOHNSON, KHADEDRA D (LPN)
Entity type:Individual
Prefix:MRS
First Name:KHADEDRA
Middle Name:D
Last Name:BROWN JOHNSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:KHADEDRA
Other - Middle Name:D
Other - Last Name:BROWN JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:451 MOUNT READ BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14606-1413
Mailing Address - Country:US
Mailing Address - Phone:585-287-4291
Mailing Address - Fax:
Practice Address - Street 1:451 MOUNT READ BLVD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14606-1413
Practice Address - Country:US
Practice Address - Phone:585-287-4291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-12
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY330069164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse