Provider Demographics
NPI:1639313869
Name:JOHNSON, LYSIMA (LPN)
Entity Type:Individual
Prefix:MS
First Name:LYSIMA
Middle Name:
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 1:10 N FULTON AVE
Mailing Address - Street 2:APT: 2F
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10550-1614
Mailing Address - Country:US
Mailing Address - Phone:914-316-1551
Mailing Address - Fax:
Practice Address - Street 1:10 N FULTON AVE
Practice Address - Street 2:APT: 2F
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10550-1614
Practice Address - Country:US
Practice Address - Phone:914-316-1551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-01
Last Update Date:2009-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY244625-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse