Provider Demographics
NPI:1477988863
Name:JOHNSON, BRANDY JACQUES (LPN)
Entity Type:Individual
Prefix:MISS
First Name:BRANDY
Middle Name:JACQUES
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 1:1140 DALLAS RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44108-3325
Mailing Address - Country:US
Mailing Address - Phone:216-323-2155
Mailing Address - Fax:
Practice Address - Street 1:1140 DALLAS RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44108-3325
Practice Address - Country:US
Practice Address - Phone:216-323-2155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-05
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.151384-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse