Provider Demographics
NPI:1265022164
Name:JOHNSON, MIKAELA C
Entity Type:Individual
Prefix:
First Name:MIKAELA
Middle Name:C
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 1:1455 RACHEL ST NW APT 24
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44709-2857
Mailing Address - Country:US
Mailing Address - Phone:330-413-6719
Mailing Address - Fax:
Practice Address - Street 1:1455 RACHEL ST NW APT 24
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44709-2857
Practice Address - Country:US
Practice Address - Phone:330-413-6719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-25
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant