Provider Demographics
NPI:1013349133
Name:JOHNSON, MICHELE TERESA (STNA)
Entity Type:Individual
Prefix:MS
First Name:MICHELE
Middle Name:TERESA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27000 ZEMAN AVE.
Mailing Address - Street 2:P.O.BOX 32425
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44132-0425
Mailing Address - Country:US
Mailing Address - Phone:216-731-1162
Mailing Address - Fax:
Practice Address - Street 1:27000 ZEMAN AVE.
Practice Address - Street 2:
Practice Address - City:EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44132-0425
Practice Address - Country:US
Practice Address - Phone:216-731-1162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-31
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401443120912376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0069987Medicaid