Provider Demographics
NPI:1366046054
Name:JOHNSON, TINA LYNETTE
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:LYNETTE
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 1:1810 FERNWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:ALLIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:44601-3837
Mailing Address - Country:US
Mailing Address - Phone:330-589-4900
Mailing Address - Fax:
Practice Address - Street 1:1810 FERNWOOD BLVD
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:OH
Practice Address - Zip Code:44601-3837
Practice Address - Country:US
Practice Address - Phone:330-589-4900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-24
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health