Provider Demographics
NPI:1043302300
Name:JOHNSON, PATRICIA LYNNE
Entity Type:Individual
Prefix:MRS
First Name:PATRICIA
Middle Name:LYNNE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 E 248TH ST
Mailing Address - Street 2:
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44123-1439
Mailing Address - Country:US
Mailing Address - Phone:216-731-4412
Mailing Address - Fax:
Practice Address - Street 1:6318 EASTONDALE RD
Practice Address - Street 2:
Practice Address - City:MAYFIELD HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44124
Practice Address - Country:US
Practice Address - Phone:440-942-5810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2658146Medicaid