Provider Demographics
NPI:1720575848
Name:JOHNSON, JUSTINE E
Entity Type:Individual
Prefix:
First Name:JUSTINE
Middle Name:E
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 1:18920 NEWTON AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44119-1125
Mailing Address - Country:US
Mailing Address - Phone:216-894-5511
Mailing Address - Fax:
Practice Address - Street 1:18920 NEWTON AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44119-1125
Practice Address - Country:US
Practice Address - Phone:216-894-5511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-13
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor