Provider Demographics
NPI:1790368801
Name:JOHNSON, LAVETA (RN)
Entity Type:Individual
Prefix:
First Name:LAVETA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 S 48TH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762-6683
Mailing Address - Country:US
Mailing Address - Phone:479-725-5243
Mailing Address - Fax:
Practice Address - Street 1:211 MISSOURI
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:AR
Practice Address - Zip Code:72342-3707
Practice Address - Country:US
Practice Address - Phone:870-338-3363
Practice Address - Fax:479-750-4843
Is Sole Proprietor?:No
Enumeration Date:2021-05-05
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR104912163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse