Provider Demographics
NPI:1164186706
Name:JOHNSON, GEORGIA (LPN)
Entity Type:Individual
Prefix:
First Name:GEORGIA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12809 CORLETT AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44105-2915
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12809 CORLETT AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44105-2915
Practice Address - Country:US
Practice Address - Phone:216-456-4208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-29
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH168809164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH168809Medicaid