Provider Demographics
NPI:1205386448
Name:JOHNSON, ALLYSSA (PA)
Entity Type:Individual
Prefix:
First Name:ALLYSSA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9001 PORTAGE POINTE DR APT E107
Mailing Address - Street 2:
Mailing Address - City:STREETSBORO
Mailing Address - State:OH
Mailing Address - Zip Code:44241-5618
Mailing Address - Country:US
Mailing Address - Phone:216-952-5151
Mailing Address - Fax:
Practice Address - Street 1:3909 ORANGE PL STE 2100
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-8400
Practice Address - Country:US
Practice Address - Phone:216-896-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-12
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
OH50-004905363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant