Provider Demographics
NPI:1811554553
Name:JOHNSON, SANDRA (LPN)
Entity Type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MS
Other - First Name:SANDRA
Other - Middle Name:H
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:3459 GIBRALTER HEIGHTS DR APT HH2
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43609-1220
Mailing Address - Country:US
Mailing Address - Phone:567-277-3414
Mailing Address - Fax:
Practice Address - Street 1:350 S. IRWIN RD
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:OH
Practice Address - Zip Code:43528
Practice Address - Country:US
Practice Address - Phone:567-703-9064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-28
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH121776.MEDS164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse