Provider Demographics
NPI:1609380476
Name:JOHNSON BLACKBURN, LEANNA SUZETTE
Entity Type:Individual
Prefix:
First Name:LEANNA
Middle Name:SUZETTE
Last Name:JOHNSON BLACKBURN
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 1:3100 LEWIS RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43207-3701
Mailing Address - Country:US
Mailing Address - Phone:614-632-0529
Mailing Address - Fax:614-350-8708
Practice Address - Street 1:5424 W BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43228-1155
Practice Address - Country:US
Practice Address - Phone:614-870-7288
Practice Address - Fax:614-870-7288
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-30
Last Update Date:2018-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.017176225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist