Provider Demographics
NPI:1497056626
Name:JOHNSON, LISA GAYE (LPN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:GAYE
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 1:221 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-1903
Mailing Address - Country:US
Mailing Address - Phone:330-721-6872
Mailing Address - Fax:330-721-6872
Practice Address - Street 1:221 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-1903
Practice Address - Country:US
Practice Address - Phone:330-721-6872
Practice Address - Fax:330-721-6872
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-04
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.120066 M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse