Provider Demographics
NPI:1104393784
Name:JOHNSON, DIONNA LATRICE
Entity Type:Individual
Prefix:
First Name:DIONNA
Middle Name:LATRICE
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 1:4417 LUCILLE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44121-3538
Mailing Address - Country:US
Mailing Address - Phone:216-334-7133
Mailing Address - Fax:
Practice Address - Street 1:4417 LUCILLE AVE
Practice Address - Street 2:
Practice Address - City:SOUTH EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44121-3538
Practice Address - Country:US
Practice Address - Phone:216-334-7133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-31
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH156162164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH07072018OtherMEDICARE
OH11151981Medicaid