Provider Demographics
NPI:1962370486
Name:JOHNSON, LITA ELAINE (CSFA)
Entity type:Individual
Prefix:
First Name:LITA
Middle Name:ELAINE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2845 SW HEATON LN
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:ID
Mailing Address - Zip Code:83647-6409
Mailing Address - Country:US
Mailing Address - Phone:208-803-8246
Mailing Address - Fax:
Practice Address - Street 1:2845 SW HEATON LN
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:ID
Practice Address - Zip Code:83647-6409
Practice Address - Country:US
Practice Address - Phone:208-803-8246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-27
Last Update Date:2025-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID100102656246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical AssistantGroup - Multi-Specialty