Provider Demographics
NPI:1235738816
Name:JOHNSON, SAMANTHA NICOLE
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:NICOLE
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 1:1785 STATE ROUTE 28 LOT 421
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:OH
Mailing Address - Zip Code:45122-9339
Mailing Address - Country:US
Mailing Address - Phone:513-707-8721
Mailing Address - Fax:
Practice Address - Street 1:1785 STATE ROUTE 28 LOT 421
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:OH
Practice Address - Zip Code:45122-9339
Practice Address - Country:US
Practice Address - Phone:513-707-8721
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-23
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide