Provider Demographics
NPI:1558142687
Name:JOHNSON, KADETRA LASHUNN (DO)
Entity Type:Individual
Prefix:
First Name:KADETRA
Middle Name:LASHUNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6815 HOUGH AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44103-3943
Mailing Address - Country:US
Mailing Address - Phone:501-542-2020
Mailing Address - Fax:
Practice Address - Street 1:6815 HOUGH AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44103-3943
Practice Address - Country:US
Practice Address - Phone:501-542-2028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-13
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH320434040423376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide