Provider Demographics
NPI:1265851596
Name:JOHNSON, TIKITA LAVETTE (LPN)
Entity Type:Individual
Prefix:MS
First Name:TIKITA
Middle Name:LAVETTE
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 1:5915 WHITE AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44103-3031
Mailing Address - Country:US
Mailing Address - Phone:216-376-8939
Mailing Address - Fax:
Practice Address - Street 1:4401 ROCKSIDE RD
Practice Address - Street 2:SUITE 212
Practice Address - City:INDEPENDENCE
Practice Address - State:OH
Practice Address - Zip Code:44131-2146
Practice Address - Country:US
Practice Address - Phone:216-520-0309
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-15
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN109725164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse