Provider Demographics
NPI:1003289687
Name:WENDY JOHNSON
Entity Type:Organization
Organization Name:WENDY JOHNSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNSER
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-343-9939
Mailing Address - Street 1:307 CLINTON ST
Mailing Address - Street 2:POX 597
Mailing Address - City:ELMORE
Mailing Address - State:OH
Mailing Address - Zip Code:43416-7703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:307 CLINTON ST
Practice Address - Street 2:POX 597
Practice Address - City:ELMORE
Practice Address - State:OH
Practice Address - Zip Code:43416-7703
Practice Address - Country:US
Practice Address - Phone:419-343-9939
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-04
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0106547Medicaid