Provider Demographics
NPI:1588218747
Name:JOHNSON, LYDIA LAJOYCE (LVN)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:LAJOYCE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10610 HWY 59 N
Mailing Address - Street 2:P. O. BOX 20 (MAILING)
Mailing Address - City:WOODLAWN
Mailing Address - State:TX
Mailing Address - Zip Code:75694
Mailing Address - Country:US
Mailing Address - Phone:903-407-9973
Mailing Address - Fax:
Practice Address - Street 1:10610 HWY 59 N
Practice Address - Street 2:
Practice Address - City:WOODLAWN
Practice Address - State:TX
Practice Address - Zip Code:75694
Practice Address - Country:US
Practice Address - Phone:903-407-9973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-26
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX347578164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX164X00000XMedicaid