Provider Demographics
NPI:1942337795
Name:JOHNSON, BEVERLY J (LPN)
Entity Type:Individual
Prefix:MS
First Name:BEVERLY
Middle Name:J
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:CALEDONIA
Mailing Address - State:OH
Mailing Address - Zip Code:43314-9493
Mailing Address - Country:US
Mailing Address - Phone:740-802-1673
Mailing Address - Fax:419-845-2075
Practice Address - Street 1:109 CENTER ST
Practice Address - Street 2:
Practice Address - City:CALEDONIA
Practice Address - State:OH
Practice Address - Zip Code:43314-9493
Practice Address - Country:US
Practice Address - Phone:740-802-1673
Practice Address - Fax:419-845-2075
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN 065827 MEDS164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2713095OtherINDEPENDENT PROVIDER