Provider Demographics
NPI:1275120669
Name:JOHNSON, STEPHEN CHARLES
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:CHARLES
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 CRYSTAL DR
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:OH
Mailing Address - Zip Code:45644-9001
Mailing Address - Country:US
Mailing Address - Phone:740-701-6444
Mailing Address - Fax:
Practice Address - Street 1:34 CRYSTAL DR
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:OH
Practice Address - Zip Code:45644-9001
Practice Address - Country:US
Practice Address - Phone:740-701-6444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-31
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH376J00000X
376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH7102049Medicaid