Provider Demographics
NPI:1699040162
Name:JOHNSON, LATRICIA
Entity Type:Individual
Prefix:
First Name:LATRICIA
Middle Name:
Last Name:JOHNSON
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 1:7897 OAK ORCHARD AVE
Mailing Address - Street 2:
Mailing Address - City:BLACKLICK
Mailing Address - State:OH
Mailing Address - Zip Code:43004-5038
Mailing Address - Country:US
Mailing Address - Phone:614-515-0879
Mailing Address - Fax:
Practice Address - Street 1:7897 OAK ORCHARD AVE
Practice Address - Street 2:
Practice Address - City:BLACKLICK
Practice Address - State:OH
Practice Address - Zip Code:43004-5038
Practice Address - Country:US
Practice Address - Phone:614-515-0879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-17
Last Update Date:2012-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN133024164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse