Provider Demographics
NPI:1689832420
Name:JOHNSON, GLENDA ALISE (05/04/1974)
Entity Type:Individual
Prefix:MRS
First Name:GLENDA
Middle Name:ALISE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:05/04/1974
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13514 KELSO AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44110
Mailing Address - Country:US
Mailing Address - Phone:216-925-6559
Mailing Address - Fax:
Practice Address - Street 1:13514 KELSO AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44110
Practice Address - Country:US
Practice Address - Phone:216-925-6559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-29
Last Update Date:2011-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH375268750696376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376G00000XNursing Service Related ProvidersNursing Home Administrator