Provider Demographics
NPI:1164776951
Name:JOHNSON, BROOK L (LPN)
Entity Type:Individual
Prefix:
First Name:BROOK
Middle Name:L
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 1:3402 STATE ROUTE 109 LOT 44
Mailing Address - Street 2:
Mailing Address - City:DELTA
Mailing Address - State:OH
Mailing Address - Zip Code:43515-9319
Mailing Address - Country:US
Mailing Address - Phone:419-270-2905
Mailing Address - Fax:
Practice Address - Street 1:3402 STATE ROUTE 109 LOT 44
Practice Address - Street 2:
Practice Address - City:DELTA
Practice Address - State:OH
Practice Address - Zip Code:43515-9319
Practice Address - Country:US
Practice Address - Phone:419-270-2905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-01
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH123788164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH123788OtherOHIO BOARD OF NURSING