Provider Demographics
NPI:1821500190
Name:LYNN JOHNSON, MARY (HOME HEALTH AIDE)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:LYNN JOHNSON
Suffix:
Gender:F
Credentials:HOME HEALTH AIDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 5TH ST
Mailing Address - Street 2:
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035-5705
Mailing Address - Country:US
Mailing Address - Phone:440-990-5938
Mailing Address - Fax:
Practice Address - Street 1:355 5TH ST
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-5705
Practice Address - Country:US
Practice Address - Phone:440-990-5938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-26
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH308354376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376J00000XNursing Service Related ProvidersHomemakerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH308354Medicaid